Skip to main content

Full text of "Dental surgery for practitioners and students"

See other formats

West Virginia University Libraries 

3 0802 102296107 6 


''■■: >.f. .T ■ ^- .' .< 

'.. .Ht 
















ASHLEY W. BAEEETT, M.B.(Lond.),M.E.C.S., L.D.S. 










Having stated as concisely as possible the substance of what 
for several years I have been teaching to students of medi- 
cine in the Dental Department of the London Hospital, I 
venture to hope that this small book may prove useful 
to the busy medical practitioner, too much occupied to 
study larger and more exhaustive works on Dental 

To such matters as the filling of teeth with gold, the 
pivoting of mineral crowns, and to others which fall only 
within the scope of the specialist, reference is intentionally 
omitted. My aim throughout has been to' give upon 
dental, matters as much practical information, and no 
more, as may suffice the student of medicine in the after 
work of his profession. 


To the practice and teaching of my uncle, H. J. Barrett, 
I am mostly indebted for what may be found to possess 
value in these pages; and to my brother, S. E. Barrett, my 
thanks are due for his assistance in revising the proof 
sheets. For the illustrations of Dental Forceps, I am 
obliged to the courtesy of Messrs. Ash and Co. 


42 FiNSBURY Squaee, 

London, E.G. 




The First Dentition. 

Eruption of Temporary Teeth. Lancing the Gums. Ab- 
sorption of Temporary Fangs. When to Extract Tem- 
porary Teeth for relief of Irregularity. Undesirability 
of Extracting Temporary Teeth. Ulceration through 
the Gums of Temporary Fangs 1 


The Second Dentition. 

Order of Eruption of Permanent Teeth. Eruption of Wis- 
dom Teeth. Diagrams of Teeth at Three Periods of 
Childhood. How to distinguish between Temporary 
and Permanent Teeth 6 


Abnormalities in Development op Permanent Teeth. 

Retarded Eruption. Supernumerary Teeth. Abortive Teeth. 
Dilacerated and Geminated Teeth. Honey-combed 
and Syphilitic Teeth . . . . . . .10 


Irregularity in the Positions of the Permanent Teeth. 


Cause of Irregularity among Teeth of the Present Time. 
Treatment of Irregularity by Extraction and the Regu- 
lating Plate. Symmetrical Extraction. Six Common 
Forms of Irregularity: — 1. Underhung Incisors; 2. 
Rotated Incisors; 3. Projecting and Diverging In- 
cisors ; 4. Projecting Canines ; 5. The V-shaped Dental 
Arch; 6. Irregular Articulation of Upper with Lower 
Teeth. The Excavator and the Mouth Mirror . .14 


Dental Caries. 

Tendency of Teeth to become rudimentary. Local and 
General Causes of Decay. Two Varieties of Caries. 
Liability of Various Teeth to Decay. General Direc- 
tions as to Treatment of Caries. Symptoms and Treat- 
ment of Caries in its First Stage. Caries in its Second 
Stage, with Antiseptic Treatment of the Pulp Cavity, 
and Symptoms and Treatment of Periodontitis and 
Alveolar Abscess. Caries in its Third Stage, with 
Contraction of Temporo- Maxillary Articulation and Fis- 
tulous opening through Cheek 27 





Odontalgia. Periodontitis. Gas Pressure on the Nerve. 

Neuralgia 50 


Mechanical Injuries to the Teeth. 

Wearing down of the Teeth from Friction of Mastication. 
Hunter's Denuding Process. Fracture and Dislocation 
of a Tooth from Violence 54 


Extraction op Teeth and Stumps. 

Conditions necessitating Extraction. General Directions as 
to the position of Operator and Patient. Concerning the 
application of Forceps. As to the Extraction of the 
Tooth. Accidents during Extraction. A list of Instru- 
ments needed for Extraction. Forceps, their General 
Characters and Various Forms. The Elevator, its De- 
scription and Mode of Using. The Screw Extractor . 57 


Anaesthetics. Preparation of the Mouth for Frames. 
Salivary Calculus 75 


Fig. 1. — Diagram from a cast of the upper jaw of a neglected 

mouth in a child aged eight .... 3 
„ 2. — At the age of three years showing the ton upper 

temporary teeth 7 

„ 3. — At the age of seven years, showing the ten tempo- 
rary teeth and also the two six-year-old molars . 8 
„ 4. — At the age of thirteen years, showing the fourteen 

upper permanent teeth ..... 9 

„ 5. — Diagram of lower jaw, showing retention of tempo- 
rary molar . . . . . . . .11 

,, 6. — Diagram of a mouth showing supernumerary teeth 

displacing incisors 11 

„ 7. — Malformed Incisor .... . ' . 12 

„ 8. — Two lower temporary incisors united by cementum 12 
,, 9. — Syphilitic Incisors ....... 13 

„ 10. — Honey-combed Incisors 13 

„ 11. — Regulating Plate for treatment of irregularity 

among the upper front teeth . . . .17 
„ 12. — Model of upper jaw with rotated incisors . . 19 
„ 13. — Model of upper jaw with widely spaced and diver- 
gent incisors 20 

„ 14. — Model of jaw with projecting canines . . .21 
„ 15. — Model of a V-shaped upper jaw . . . .22 
„ 16. — Excavator . . . . , , . .24 
,, 17. — Mouth Mirror 25 



Page 45, line 3 from bottom, and page 56, last line, 
for Rhizodontrophy read Rhizodontropy. 


Fig. 18. — Nerve Extractor for removing devitalized dental 

nerve . 38 

,, 19. — Upper incisor and canine forceps . ... . QQ 
„ 20. — Upper bicuspid forceps for either side . . , Ql 
„ 21. — Forceps for lower incisors, canines and bicuspids . 68 
,. 22. — Forceps for upper right molars , . . « 69 
,, 23. — Forceps for upper left molars . . . .70 
„ 24. — Lower molar forceps for either side of the mouth . 70 

„ 25. — Upper stump forceps .71 

„ 26. — Lower stump forceps .71 

„ 27. — Elevator — front view . . . . . .73 

„ 28. — Elevator — ^^side view . . . . . .73 

„ 29. — Screw extractor for removal of stumps of upper 

incisors and canines . . . , . . 74 
„ 30. — Telescopic gag or mouth prop, for use during in- 
halation of nitrous oxide 76 

„ 31. — Mouth opener, to be used with the administration 

of chloroform . 77 



Chapter I. 


Eruption of Temporary Teeth. Lancing the Gums. 
Absorption of Temporary Fangs. When to Extract 
Temporary Teeth for relief of Irregularity. 
Undesirability of Extracting Temporary Teeth. 
Ulceration through the Gums of Temporary Fangs. 

The temporary teeth are twenty in number, and their 
eruption usually begins and ends between the ages of six 
months and two and a half years. The following table 
gives the order and times of cutting of the various mem- 
bers of this series. 

The 2 Lower Central Incisors, about 6th Month. 

2 Upper 

2 Lower Lateral 

2 Upper 

4 1st Molars 

4 Canines 

4 2nd Molars 

„ 8th 

„ 10th 

„ 12th 

... „ 16th 

... „ 20th 

... „ 30th 

The protrusion of the tough unyielding gum by a grow- 
ing tooth is apt at times to be attended with much sufifer- 


ing, evinced by a greatly increased flow of saliva, with febrile 
symptoms and convulsive movements. Belief may be 
then afforded by passing a well protected lancet through 
the whitened nodule of gum down to the erupting crown. 
Such an operation should, however, be performed only 
when the mucous membrane of the mouth is in a healthy 
condition, and when also it is quite evident to the sense of 
touch, that the cutting edge of the new tooth is bound 
down by the tense and fibrous gum. 

At the age of four years absorption of the fangs of the 
temporary teeth commences and those of the incisors are 
first attackedy This process, in its nature purely vital and 
in no way mechanical, is brought about by the action of 
the Absorptive Papilla, a mass of many nucleated cells that 
lies closely behind and eating into each temporary fang, 
and intervening between the latter and the crown of its 
permanent successor. 

/ A growing permanent tooth is placed immediately behind 
and below the fang of each temporary incisor and canine, 
while underneath each temporary molar, and embraced 
within its widely diverging fangs, is the crown of the 
bicuspid that is to take its place. A knowledge of the 
latter fact is of value when it becomes necessary to extract 
a temporary molar, and the forceps should then be applied 
with caution and not thrust deeply into the alveolus, lest 
the permanent be taken out with the temporary tooth. 

It is not often necessary to extract a temporary tooth to 
make room for its permanent successor, since the rapid 
development of the jaw and consequent expansion of the 
alveolar arch that occurs during childhood tends to per- 


mit permanent teeth to fall into their normal situations, al- 
though at the time of, and shortly after their eruption, they 
may have been crowded out of line. Under these circum- 
stances, however, the extraction of a temporary tooth for 
the relief of irregularity may become necessary. If such a 
tooth or its decayed fang be retained considerably after 
the time at which it should normally be shed, while an un- 
usual degree of fixity in its socket shows that the action of 
the Absorptive Papilla upon its fang has been but slight ; 
if also the eruption of the crown of its permanent successor 
has well advanced, while the line in which the * latter is 
growing diverges considerably from its normal direction ; 
if these conditions be present the obstructing temporary 
tooth may with advantage be removed. It becomes quite 
necessary that this should be done when the irregularity 

Fig. 1. 

Diagram from a cast of the upper jaw of a neglected mouth in a child 
aged eight. The four permanent incisors have erupted, so that they bite 
within and behind the lower teeth when the mouth is closed. The four 
temporary are unduly retained with their fangs but slightly absorbed. 



occurs among the upper front teeth, for if a permanent 
Upper Incisor or Canine be allowed to grow so irregularly 
that when fully erupted it bites behind the lower teeth, it 
becomes necessary to adopt a course of tedious dental 
treatment that might have been avoided by a timely re- 
moval of a temporary tooth. 

The temporary molars are prone to early and rapid de- 
cay ; their dental pulps are large, highly sensitive, and 
ready, as the result of such quickly advancing caries, to 
take on a process of destructive inflammation, thus becom- 
ing rapidly devitalized and decomposed. The treatment, 
however, of decay with its sequelae among temporary and 
permanent teeth must be referred to later on. Suffice it 
now to say that a badly developed and carious set of per- 
manent teeth does in no way necessarily occur in a mouth 
which may have been conspicuous by the faulty character 
of its milk teeth. Also it should be noted that temporary 
molars should never be extracted save as a last resource 
and when every attempt to relieve pain by other means 
has failed. Small cavities occurring in them, should if 
possible be filled before decay has encroached greatly upon 
their walls, and in so doing it is well always to avoid caus- 
ing pain to the child. Carious dentine and enamel 
should be very lightly removed, and for the stopping of the 
cavity such a material as gutta-percha gently warmed 
over a candle flame, or cotton wool that has been dipped 
into a solution of gum mastic in alcohol, answers admir- 
ably. Decay when more advanced, with death of the pulp 
resulting, may necessitate other treatment ; but always this 
should be remembered, that a broken down temporary 


molar, if only it be not causing pain, is better than none 
at all and may be invaluable to the child for the mastica- 
tion of its food and the due nutrition of its body. 

It has been said that it is occasionally necessary to ex- 
tract temporary teeth to prevent irregularity. Under these 
conditions also they may require to be removed ; when as 
the result of the absorption of the posterior surfaces of their 
fangs, the sharp ragged ends so resulting have ulcerated 
through the gum and have wounded the lip or cheek. 
The laceration and inflammation of the soft parts is apt 
to be more severe when it results from a lower than when 
caused by an upper fang, owing to the greater mobility of 
the tissues around the former. The trouble of course 
ceases as soon as the cause is recognised and removed, but 
the condition should be carefully noted, lest it be wrongly 
attributed to necrosis and exfoliation of a portion of the 


Chapter II. 

Oeder of Eruption of Permanent Teeth. Eruption of 
Wisdom Teeth. Diagrams of Teeth at Three 
Periods of Childhood. How to distinguish between 
Temporary and Permanent Teeth. 


The order and times of eruption of the permanent teeth 
are as follows :— 

The 4 1st Molars at about the 6th year. 



„ 2 Upper „ „ 

J J f UXX J) 

„ 8th „ 

„ 4 Lateral Incisors „ 

„ 9th „ 

,, 4 1st Bicuspids ,, 

„ 10th „ 

„ 4 2nd „ 

„ 11th „ 

,, 4 Canines „ 

„ 12th „ 

„ 4 2nd Molars ,, 

„ 18th „ 

„ 4 3rd Molars „ 

„ 20th „ 

As a rule but little local or general disturbance attends 
the eruption of the permanent teeth. They grow up he- 
land their temporary predecessors which in due course 
become loosened and are shed. And thus the process is 
quietly effected without attracting much notice. 

The cutting of the lower wisdom tooth is often, however. 


attended with a good deal of suffering. A flap of gum is 
lifted up by its growing crown and between this last and 
the upper second molar the gum structure is liable to be 
bruised during mastication. Eelief may at times be given 
by incising the constricting tissue and by touching the in- 
cised surface lightly with nitrate of silver. Usually the 
pain and inflammation subside in the course of a few days, 
and the treatment of such cases may generally be hmited 
to the use of hot fomentations inside the mouth. If, how- 
ever, the erupting third molar be impacted between the base 
of the coronoid process and the back of the second molar its 

Fig. 2. 

At the age of three years showing the ten upper temporary teeth. 

Two Temporary Central Incisors, 
„ „ Lateral „ 

,, ,, Canines. 

,, ,, 1st Molars. 

,, ,, 2nd Molars. 

extraction may become necessary, and if this be found to 
be quite impracticable it may be needful to remove the 
second molar to give relief. It should of course be borne 



^aVtUk* mind that a second molar is perhaps more useful and 
durable than any other tooth in the mouth, so that its ex- 
traction should be regarded as quite a last resource. / 

The accompanying diagrams represent the upper teeth at 
three characteristic periods of childhood. 

Fig. 3. 

At the age of seven years, showing the ten above mentioned temporary 
teeth, and also the recently erupted 1st permanent or six year old molars. 

Two Temporary Central Incisors, 
J, ,, Lateral „ 

„ ,5 Canines. 

„ „ 1st Molars. 

,, „ 2nd Molars. 

,, Permanent 1st Molars. 

The need for being able to decide on examining a mouth, 
whether any given tooth be temporary or permanent is 
evident. As a rule there is no difficulty in so doing. 
The permanent incisors are larger and more yellow in tint 
than those of the milk dentition, while their cutting edges 
are serrated for a year or two after eruption. Later on the 


serrations become obliterated, as occurs among young milk 
teeth which are soon worn smooth by the friction of eating. 
The bicuspids can not easily be mistaken for the tem^^orary 

Fig. 4. 

At the age of thirteen years, showing the fourteen upper permanent 
teeth. All the temporary teeth have been replaced by their ten corres- 
ponding permanent ones, and also the 1st and 2nd permanent molars have 
been cut. The six temporary incisors and canines have been replaced by 
the six permanent incisors and canines j and the four temporary molars 
have been replaced by the four bicuspids. 

Two Permanent Central Incisors. 

aj ,, j^aLerai ,, 

,, ,, Canines. 

„ ,, 1st Bicuspids. 

,, ,, 2nd Bicuspids. 

,, ,, 1st Molars. 

„ ,, 2nd Molars. 

molars which they replace, but it is well to guard against 
extracting a permanent canine tooth under the impression 
that it is the corresponding temporary one, and also the first 
permanent molar should not be mistaken for the second 
temporary one. 


Chapter III. 


Ketaeded Eruption. Supernumerary Teeth. Abortive 
Teeth. Dilacerated and Geminated Teeth. Honey- 
combed AND Syphilitic Teeth. 

Betarded erujjtion. — The cutting of a permanent tooth may 
be delayed long after the normal time, or its absence may 
continue through life. To teeth thus buried and but partly 
developed'have been attributed myeloid and other growths 
which have been found within the maxillae in their neigh- 
bourhood. Whether it be true or not that such tumours 
have arisen from such causes, the author is unable to say, 
but he is inclined to believe the dental irregularity to have 
been merely a coincidence with, or even a result of, the pro- 
gress of the diseased growth. At times an incisor or 
canine tooth may remain throughout life embedded in the 
the palatine process of the upper maxilla or but partially 
erupted from its lower surface. A lower wisdom tooth 
has been removed from the cheek, near the angle of the 
jaw, where its late eruption caused much distress and 

Irregularity in excess of the normal number. — Such addi- 
tional teeth are Supernumeraries. They are usually found 
in the front of the mouth, in the neighbourhood of the upper 



permanent incisors, among which by their presence they 
may cause a good deal of irregularity. Supernumerary 
teeth are more or less conical, with stunted fangs. As a 

Fig. 5. 

Diagram of a model of the right side of a lower jaw aged 36. All the 
lower permanent teeth are erupted with the exception of the 2nd bicus- 
pid. The 2nd temporary molar is retained and serves to illustrate the 
difference in level between the temporary and permanent 


Fig 6. 

Diagram of a mouth aged 13. In the front of the mouth are two super- 
numerary teeth v^rhich are displacing permanent incisors from their 
rightful positions. 


rule it is well to extract them, if by their presence they are 
causing the normally developed teeth to take up improper 
positions in the dental arch. 

Abortive Teeth, — A tooth though normally placed in the 
series may be irregular in form. Annexed is a drawing of 
a permanent central incisor, or of what corresponded there 
with, which was removed on account of its deformity from 
a patient in the dental department of the London Hospital. 

Fig. 7. 

Further as the result of developmental irregularity, the 
long axis of a tooth may be bent at an angle near its neck, 
when it is said to be dilacerated. Also two adjacent teeth 
may be geminated, or united by their adjacent surfaces, the 
union being sometimes so complete that they have but one 
common pulp cavity. 

Fig. 8. 

Two lower temporary incisors united by 
cementum on their adjacent sides. 

Certain structural defects may be evident among all the 
teeth of the permanent series. 


Honeycomhed or Strumous Teeth, — The incisors and first 
molars most often present the appearance of such. These 
are dark-yellow in colour and deeply pitted or ridged 
transversely upon their surfaces, as though the deposition 
of enamel had been injuriously affected during the develop- 
ment of the organs. The inheritance of a strumous dia- 
thesis, or overdosing with mercury in early childhood, 
have both been said to have induced this condition, but its 
cause is still obscure. A careful distinction must be drawn 
between this and the following abnormality. 

Syphilitic or Speci^c Teeth, — These, the result of inherit- 
ance of the syphilitic taint, show the following well marked 
characteristics : — One crescentic notch in the middle of the 
cutting edges of the upper and lower permanent incisors. 
These teeth are also separated from each other ; are of 
dark colour, and of peg-top shape. The development of 
the bicuspids and molars is also modified, but the central 
notch of the incisors is most typical of the diathesis. The 
temporary teeth of children with syphilitic parentage pre- 
sent no peculiar traits. The annexed two diagrams are 

Pig. 9. Fig. 10. 


Syphilitic Incisors. Honeycombed Incisors. 

from drawings by Mr. Hutchinson, and show the features 
of typically marked honeycombed and syphilitic permanent 
upper central incisor teeth. 


Chapter IV. 


Cause of Irregularity Among Teeth of the Present 
Time. Treatment of Irregularity by Extraction and 


Six Common Forms of Irregularity: — 1. Underhung 
Incisors ; 2. Eotated Incisors ; 3. Projecting and 
Diverging Incisors ; 4. Projecting Canines ; 5. The 
V-shaped Dental Arch ; 6. Irregular Articulation 
OF Upper with Lower Teeth. The Excavator and 
THE Mouth Mirror. 

Irregularity in the arrangement of the permanent teeth 
is among civiUzed races greatly on the increase, and 
its cause may be found in the lessened work thrown 
upon the organs of mastication by the appliances and 
requirements of modern life, whence results decreased 
development of both teeth and jaws. But while the shape 
size and number of the teeth has not undergone much 
change, with the exception of the wisdom-tooth which is 
now more variable and less developed than in skulls of 
earlier date, we find that the development of the maxillary 
bones is frequently far less complete than in the older 
periods of man's history. So, with a stunted alveolus and 


teeth of normal size, overlapping and crowding of the latter 
too often ensues. 

Such irregularities are so varied that an altogether satis- 
factory method of classifying them is not very practicable. 
The common and typical deformities are therefore only 
described and it must be noted that any one may co- exist 
with other forms. Irregular and overlapping teeth when 
occurring in the front of the upper jaw are more unsightly 
than when they are found in the lower, but under all cir- 
cumstances it is desirable that the teeth should be evenly 
arranged in the maxillae. Behind projections and between 
•overlapping teeth the food that always collects and is apt 
to escape the cleansing action of the tooth brush will cer- 
tainly decompose and thus favour the attack of caries. 

For the curing of irregularity, we have two methods of 
treatment which may be applied singly or combined ; we 
may extract teeth to give additional room, or we may em- 
ploy a regulating plate to produce a like effect by forcing 
the teeth outwards and so expanding the dental arch. If 
extraction alone be practised these points should be noted. 
The front teeth, and especially the canines, should if possible 
be spared, since the loss of the two upper eye teeth is apt to 
alter the appearance of the face by the considerable absorp- 
tion of alveolar process that follows their extraction and 
the consequent sinking in of the angle of the mouth. The 
canines moreover have more value for purposes of mastica- 
tion than other front teeth, since they are less liable to decay 
and are more firmly implanted in the alveolar sockets. 
Before deciding which teeth may best be spared careful ex- 
amination of the mouth with the assistance of a fine exca- 
vator and a mouth mirror should be made. 


If all bicuspids and molars be well developed and free 
from decay then the best and speediest mode of curing the 
irregularity may be by the removal of the two upper and 
possibly also of the two lower first bicuspids. But if as is 
more likely to be the case, decay be present among the 
first permanent molars, two or four of these should be ex- 
tracted. It is upon these teeth that the choice will pro- 
bably fall since, from a cause that has not yet been 
ascertained, dental decay is more prevalent and commences 
earlier among the first molars than among other teeth. 

Such extraction should be practised symmetrically. If 
an upper molar or bicuspid on one side be removed, then 
also the corresponding tooth on the other side of the mouth 
should be taken out ; or if of the four six-year-old molars, or 
of the four 1st bicuspids, two only, an upper on the right and 
a lower on the left, be decayed, or if three of the series be 
carious and the other sound, then the extraction should be 
completed as regards all four corresponding teeth. Thus 
from a timely and judicious symmetrical extraction will often 
follow a natural and symmetrical regulation of the crowded 
front teeth, and the forces tending to bring this about are 
the continuous pressure exerted upon the dental arches 
by the lips and muscles of the face and the tongue. 

If then it be advised to part with four 1st molars, the time 
most suited for such extraction is that at which the four 
2nd, or 12-year-old, molars are just erupting. The latter 
then advance and in two years time the spaces resulting 
from extraction are nearly obliterated. Although the re- 
moval of four decayed first molars may hardly serve of it- 
self to materially alter the positions of much overlapping 



front teeth, yet the additional room thus gained in the 
mouth can not but be sahitary, since the increase of the 
irregularity from the pressing forward of erupting and ad- 
vancing back teeth is certainly arrested. Also the more 
perfect cleansing and polishing of the sides of bicuspids and 
molars which is rendered practicable by the slight separa- 
tion that ensues among them conduces very greatly to 
their ultimate preservation from caries. 

The regulating plate, usually of vulcanite or gold, is con- 
structed by the dentist to a plaster model of the jaw with 
its contained irregular teeth. Such a plate carries elastic 
gold wires which looping over the outstanding teeth serve 
to draw them back into line, and also if needed it may con- 
tain small wooden pegs to press upon the posterior surfaces 

Fig. 11. 

Vulcanite regulating plate for treatment of irregularity among the upper 
front teeth, showing the gold wires and wooden pegs referred to. 

of back- standing teeth. Thus by the forcing of these out- 
wards the dental arch is expanded and increased room ob- 
tained for the reduction of any irregularity. 



During the wearing of all regulating plates great cleanli- 
ness should be observed; the teeth being brushed with 
soap and water each morning and evening, and the plate 
being taken from the mouth after every meal to be brushed 
in like manner on both surfaces. If this be done a regu- 
lating plate may be safely worn for several months, but if 
it be omitted the acid produced by decomposition of food 
and sahva will shortly soften and erode the crowns of the 

The irregularities most often met with are as follows : — 
1. One or more permanent incisors may be erupted con- 
siderably behind the Hne of their neighbours, as the result 
of undue retention of temporary teeth {vide fig. 1, Chap. I). 
This may be prevented by the judicious removal of the latter 
when required, but if the abnormality happen to upper front 
teeth these may be found to be underhung, or to bite be- 
hind the lower incisors when the jaws are closed. In 
this last case a regulating plate {vide fig. 11) mus be worn 
for three or four weeks, which shall force out with the aid 
of steel screws, or a series of wooden pegs each longer than 
its predecessor, the back- standing tooth or teeth. That this 
may be effected the jaws must be kept a httle apart by 
carrying the vulcanite plate over the masticating surface 
of the molars and bicuspids, and but a short course of such 
treatment will be needed to push forward the back- standing 
upper incisor, so that its lower antagonist shall close be- 
hind rather than, as was the case before treatment com- 
menced, in front of it. As soon as this changed condition 
is brought about the regulating frame may be left off, 
since the misplaced tooth cannot relapse into its old posi- 


tion, and the closure of the lower jaw upon the upper will 
shortly induce a symmetrical arrangement of the upper 
front teeth. 

2. An incisor tooth may be partly rotated on its long 
axis {vide fig, 12). This should be treated with a regulating 
plate constructed to draw back, by the aid of a gold wire, the 
projecting margin, and with a wooden peg to push out the 
side of the tooth that is so rotated inwards. A few years 
back it was not unusual to forcibly turn such teeth into 
proper position with the aid of forceps. This course is 
not to be recommended, as the disruption that it causes to 
the nerves and vessels entering the tooth at the end of its 
fang is very liable to induce death and early loss of the 

Fig. 12. 

Model of upper jaw with rotated incisors. 

3. The upper incisor teeth may be widely spaced and 
divergent {vide fig. 13). Such cases are best treated by 
the dental surgeon, who, if there be no obstacle to regu- 
lation, such as a pressure upon their back surfaces of the 
lower incisors, may draw in two divergent centrals by 
placing around their necks a thin elastic band. It must 
be noted that such treatment needs close watching, and 



the band must be prevented from forcing itself up the 
necks of the teeth beneath the gum by attaching to it one 
or more gold wire loops, which may be hooked over the 
cutting edges of the teeth that are being operated upon. 
If this be neglected the latter will certainly be loosened 
and will probably be lost. 

Fig. 13. 

Model of upper teeth with widely spaced and divergent incisors. 

4. The canines may greatly project while the incisors are 
overlapping (vide fig. 14). This is a very common form of 
irregularity, and is doubtless favoured by the later eruption 
of the eye-teeth, as compared with that of the incisors and 
bicuspids, whereby the former find the spaces into which 
they should normally fall in the dental arch closed to their 
admission by the approximation of the lateral incisors with 
the first bicuspids. In such an irregularity much improve- 
ment may be hoped for with time and during that growth 
and expansion of the maxillas which continues for a few 
years after the canines are erupted. Should this, however, 
seem insufficient to provide such space as may be required 
by the projecting eye-teeth it will be necessary to extract 



first bicuspids, and into the gaps caused by tlieir removal 
the former will in all probability be conducted by the 
gentle but continuous pressure upon their outer surfaces 
of the muscles of the lips and cheeks. More complete 
symmetry may with certainty be given to the dental 
arch if, in addition to extraction of bicuspids, a vulca- 
nite regulating plate be employed for a few weeks to 
draw back the canines, and at the same time to push 
out into a symmetrical curve the irregular and crowded 
incisor teeth. 

Fig. 14. 

Model of upper jaw, aged 14 years. The canines are projecting but 
these were subsequently drawn backwards and inwards by a dental plate 
into the spaces caused by the removal of the first bicuspids. At the 
same time the four incisors were pushed slightly outwards by wooden 
pegs connected with the frame. The model was taken a month after re- 
moval of the two 1st bicuspids. 

5. A V-shaped dental arch may be combined with a 
deeply vaulted palate {vide fig. 15), and this form of irregu- 
larity is often associated with congenital idiocy. The upper 


j;Sl«M UMlv^ 



teeth are here found to be arranged along two more or less 
straight lines converging towards and meeting at the front 
of the mouth. Treatment should go in the direction of 
expanding the arch by regulating plates,. and of gaining 
additional room by a judicious thinning out of bicuspids 
or first molars. 

Fig. 15. 

Model of a V-shaped upper jaw. This was co-existing with a vaulted 
palate and idiocy of a congenital nature. 

The V-shaped arch, and the form of irregularity to be 
next described, are frequently transmitted by inheritance, 
and it is not unusual to find a like defect among all the 
children of parents presenting either of these deformities. 
It cannot be disputed that such errors in maxillary develop- 
ment are infinitely more frequent among civilized than 
among savage races, and though the V-shaped arch and a 
deeply vaulted palate may co- exist with well developed 
cerebral organs, yet, as Dr. Langdon Down has pointed out, 
{Transactions of Odontological Society, 1871), it is extremely 


common to find such well marked defects in the mouths of 
congenital idiots, and this, as the same authority has stated, 
possesses practical value. Given a V-shaped arch and 
vaulted palate in the mouth of an idiot, we may assume that 
the defective development in mouth and brain results from 
a cause which acted prior to the birth of the patient ; that 
the idiocy was congenital. If, on the other hand, a nor- 
mally developed mouth co-exist with idiocy it is probable 
that the latter was acquired after birth. Concerning the 
treatment of the former a more favourable prognosis 
may be given, since a brain imperfectly developed is more 
amenable to treatment than one whose functions have been 
impaired by some grave lesion induced after birth. 

6. In a less common form of irregularity, which like the 
V-shaped arch is frequently hereditary, we find the cutting 
edges of the lower incisors set at a level higher than that of 
the grinding surfaces of the lower bicuspids and molars. 
As a result of this the upper incisors are gradually bitten 
out and loosened by the pressure upon their backs of the 
lower teeth whenever the jaws are closed. 

In a case such as this, lately under treatment, the only 
plan that promised ultimately to be successful in prevent- 
ing the loss of the two upper central incisors was to adapt 
a thin gold plate to the grinding surfaces of the lower masti- 
cating teeth, and thus the lower front teeth were kept out 
of reach of the upper ones which they were rapidly destroy- 
ing. Before the wearing of this plate, which served only to 
prevent increase in the irregularity and in no way tended 
to reduce it, a prolonged but quite unsuccessful attempt to 
improve the positions of the upper and lower teeth had 


been made. The four first bicuspids had been removed ; 
the lower incisors had been shghtly shortened by fihng 
away a httle from their cutting edges ; the lower incisors 
with the lower canines had been drawn back by a vulcanite 
regulating plate ; this being effected, the projecting upper 
incisors and canines were then drawn in by the continuous 
and gentle contraction of an elastic band passed round the 
back of the head and attached to each end of a narrow 
gold band that impinged upon the front surfaces of the 
six projecting upper front teeth. By this prolonged 
treatment the irregularity was almost entirely cured, 
but on discontinuing the apparatus the case unfortu- 
nately relapsed into something much like its first con- 
dition, through the renewed pressure upon the backs of 
the upper front teeth of the cutting edges of the lower 
ones. From this it may be inferred that malformations of 
this nature are less amenable to treatment than those spoken 
of before. 

Fig. 16. 

An excavator for use in examination of teeth and preparation 

of cavities. 

The Excavator (videfi^. 16) should be strong and well tem- 
pered, so that it may neither readily bend nor break. While 
the operator is conveying it towards the patient's face and 
into his mouth, its cutting edge should be pressed firmly 
against the end of the second finger, that there may be no 
chance of wounding either face or eyes by any incautious 



movement on the part of the patient. The excavator may 
be used as a probe to search for half concealed stumps, or 
to explore a cavity in a carious tooth. In doing the last 

Fig. 17. 

A mouth mirror for use in examination of the teeth. 

guard against wounding a sensitive dental pulp and so in- 
flicting much unnecessary pain. Also the excavator may 
be employed to prepare a cavity for the reception of a 


gutta-percha or other stopping by cutting away softened 
and decayed tooth structure. It may be used to carry into 
the mouth a dressing of absorbent wool, which may be used 
as a mop to remove blood or saliva from the part to be 
operated upon. Also the excavator is of great value in 
enabling us to learn if the tooth to be extracted is rigidly 
implanted in the maxilla or is at all moveable. When used 
thus, the instrument, which should be a specially strong 
one, should rest upon a solid part of the crown of the tooth, 
and thus, with a very small amount of force, most teeth 
may be slightly moved laterally to and fro. Such mobility 
may teacli the operator that no special difficulty is to be 
expected in the removal of the tooth ; but if the latter be 
glued down into its socket by inflammatory exudation, or if 
its fangs be solidly implanted in a massive and unyielding 
maxilla, we shall not succeed in producing any movement 
of its crown by manipulation with the excavator. 

The Mouth Mirror (vide fig. 17) is of value when it is 
desired to reflect a ray of light upon some obscure situa- 
tion in the mouth, and also for showing cavities in the 
backs of molar teeth. It is well before its use to slightly 
warm it in hot water, or over the lamp, in order that its 
face may not be clouded by moisture condensed from the 


Chapter V. 

Tendency of Teeth to Become Eudimentary. Local and 
General Causes of Decay. Two Varieties of Caries. 
Liability of Various Teeth to Decay. General 
Directions as to Treatment of Caries. Symptoms 
AND Treatment of Caries in its First Stage. Caries 
in its Second Stage, with Antiseptic Treatment of 
the Pulp Cavity and Symptoms and Treatment of 
Periodontitis and Alveolar Abscess. Caries in its 
Third Stage, with Contraction of Temporo- Maxillary 
Articulation and Fistulous Opening Through Cheek. 

Dental decay is far more prevalent among the civilized 
races of the present day than among the aboriginal tribes 
of Africa, America, and Australia ; also an examination of 
ancient skulls proves it to be one of the incidents of advanc- 
ing civilization. This is the outcome of several causes : 
such as the preservation of the weakly and their greater re- 
production that now obtains ; the general lessening of bodily 
vigour and development that is apt to go with increased men- 
tal cultivation ; and the smaller need for dental organs that 
comes from improvement in the quality and preparation of 
modern food. It is perhaps not easy to say what degree 
of value should be set upon this last, but certain it is that 
the teeth and jaws of to-day have far less work thrown upon 
them than in times when man lived upon roots and iniper- 


fectly prepared coarse flesh, and we may assume that the 
development of the teeth, as of other organs, varies with the 
amount of labour they are called upon to perform. The 
frequent absence of one or more third molars, their often 
late eruption, and their commonly dwarfed size ; the in- 
crease of dental caries ; and the tendency to early shedding 
of the teeth from absorption of their alveolar sockets, all 
suggest that the dental organs of civilized man are tending 
to become rudimentary. 

vThe local conditions predisposing to decay are twofold ; 
defective development of dentine and enamel, and abrasion 
and crushing of the latter from overcrowding of the teeth. 
If either condition be present the tooth, like a badly built 
house, admits moisture into its interior.) The evidence of 
defective development may be found in those linear cracks 
between the cusps of molars and bicuspids, or upon the 
back surfaces of upper lateral incisors, which a careful 
scrutiny will often reveal shortly after their eruption. 
\The abrasion of enamel which favours decay occurs m 
crowded mouths upon the lateral surfaces of bicuspids, 
which by their slight mobility during mastication are ren- 
dered liable to such injury. "With such defects present in 
the structure of a tooth it is certain that saliva and debris 
of food will find their way into its interior, there to decom- 
pose and generate those acids which serve to dissolve out 
its lime salts. Dental decay consists essentially in the 
solution and separation of the earthy or inorganic salts of 
a tooth, from its animal matrix, and chiefly of this last 
does carious dentine consist. The reaction of the latter is 
markedly acid to litmus paper,! and microscopic examina- 


tion reveals upon its surface, and within its tissue, a copi- 
ous development of the cryptogam, Leptothryx Buccalis, 
the sporules of which penetrate into and between the den- 
tinal tubules. Although the existence of this is perhaps 
not essential to decay, since a healthy tooth may be decal- 
cified by immersion in acetic acid, yet we may believe that 
the growth of the cryptogam favours the decomposition of 
the dentine by exercising upon it such a catalytic action as 
is induced by the introduction of the yeast plant into a 
saccharine solution. (The dentine of a tooth is always 
more prone to decay than its enamel, and while the latter 
is solid and free from defects a tooth will always withstand 
such injurious influence as may be brought to bear upon it. 

As a rule decay radiates throughout the dentine from 
the bottom of enamel flaws, and the presence of mischief 
is often not revealed by pain or oth^ symptoms until the 
force of mastication crushes in the roof of enamel that 
arches over a mass of yielding and disintegrated dentine. 
Caries will at times take another form and appear as a 
general softening of enamel and dentine around the necks 
of various teeth. Such a condition is apt to occur about 
the middle period of life when the recession of the gums 
and commencing absorption of the edges of the alveolar 
plates expose to the action of the saliva the softer and 
less durable cementum that coats the fangs. 

The tendency to caries shown by various teeth difl'ers 
greatly. Those most liable to it are the four six- year-old 
molars, and of all decayed teeth extracted by the operator 
about one third will belong to this series. Those least 
liable to this disease are the four lower incisors and two 


lower canines, but why the development of the six last should 
be more complete than that of the four former is at present 
unknown. The fact, however, remains and to it we may 
attribute their far greater longevity. 

With the condition of the health generally the tendency 
to decay naturally varies, and so our efforts to combat the 
latter should be both general and local, in their nature. 
The local treatment of a carious tooth should have a 
double aim ; firstly, to relieve the toothache which is 
usually the exciting cause of our patient's visit ; secondly, 
to preserve the tooth usefully and to retard or prevent the 
extension of caries. It is evident that the insertion of gold 
fillings, which is usually the most successful way of effect- 
ing the last, is as much outside the work of a medical 
practitioner as is the making of plates for artificial teeth. 
Indeed, the filling of a tooth with any material, be it 
oxychloride of zinc, amalgam, or gold, in such a way as to 
make a perfectly water-tight durable plug that shall with 
certainty prevent any extension of disease for a number of 
years, must come within the scope only of such practi- 
tioners as devote their whole time to such work. Still 
much remains that a doctor may do for a patient who is 
unable to visit a specialist. He may by treatment of the 
tooth, or its extraction, relieve pain, and he may usefully 
prolong its existence, though he can hardly hope to per- 
manently save it, by carefully filling the carious cavity 
with a plug of gufcta-percha or wool and mastic. 

The course of dental caries varies greatly in duration 
with the habits, health, and age of the patient, being most 
rapid for a few years after the attainment of puberty. 


We may divide it into three stages. Each of these condi- 
tions presents well-marked and unvarying characters, 
and familiarity with them is the more necessary since 
treatment that serves to relieve pain from caries in its 
first stage would, if adopted in the second, make matters 
very much worse. 

Caries in its First Stage. 

Symptoms. — The first stage of caries endures until the 
dental pulp or any portion of it has become gangrenous. 
The patient complains of severe intermittent pain, in- 
creased and induced by cold water, hot fluids, the sucking 
of air from the carious cavity by the tongue, and the pre- 
sure of food within it during mastication. Frequently the 
carious and aching tooth cannot be exactly indicated by 
the sufferer. Pain, as he says, flies round the teeth so 
that he hardly knows which is in fault. Careful examina- 
tion with the aid of a mouth-mirror, and an excavator 
carrying a small dressing of absorbent wool, will usually 
reveal a cavity of moderate size in some tooth around 
which pain seems to centre. Our examination shows : — 
1. The tooth is not discoloured. 2. Pain is not complained 
of when a moderate pressure is made upon a sound por- 
tion of its crown with a strong blunt pointed excavator, 
and the absence of such pain shows that the tissues out- 
side and embracing its fangs are in a normal condition. 
Guard, however, against being deceived by the starting 
and flinching in which nervous patients will indulge at the 
moment of contact of the excavator with the tooth. A 


good plan is to test other teeth near the suspected and 
carious one before coming to the latter. 3. Most acute 
and darting pain is felt when the edge of the excavator is 
inserted into the decayed dentine in the floor of the cavity, 
or when the dressing of wool is wiped across its surfaces 
Be it remembered that this should be very cautiously and 
gently conducted, the walls and floor of the cavity being 
stroked rather than cut with the instrument, since intense 
pain may readily be caused and the dental pulp, if not ex- 
posed by the progress of decay, may be thus accidentally 
laid bare. 4. The crucial test, to ascertain if the nerve be 
still alive and sensitive, ^.6., if the caries be still in its first 
stage, may now be applied. Inject from the nozzle of a small 
syringe three or four drops of cold water into the cavity in 
the tooth. This will cause severe though momentary pain, 
but before inflicting it the patient should be cautioned that 
what is about to be done will probably produce this re- 
sult. These four conditions then ; the absence of dis- 
colouration, the absence of tenderness on pressure upon 
the crown of the tooth, the sensitiveness of the decayed 
dentine, and the pain caused by injecting cold water, go to 
show that the nerve is alive and in a normal, though per- 
haps irritated condition, and that the first stage of 
caries still continues. 

Tkeatment. — The cavity small and nerve not exposed, or ex- 
posed by only a small opening through the ivall of thepuljj cavity, 
OarefuUy examine the bottom of the cavity to learn if the 
nerve be exposed, which, if such be the case, may be seen 
as a bleeding highly sensitive spot. If this be not evident, 
or if the point of exposure be very minute and the cavity 


of small or moderate size and so situated in tlic tooth that 
a plug of wool if inserted will be retained, a temporary 
filling may be applied. Before doing this all irritating 
particles of food should bo washed from the cavity by 
syringing with ivarm water, and its Avails and floor should 
be dried by gentle wiping with a dressing of absorbent 
cotton-wool upon the end of an excavator. The filling 
may consist of Wool with Carbolic acid. Wool with Tinc- 
ture of Mastic, or Gutta-percha. The first may be used 
if the walls of the cavity are very sensitive, if the nerve be 
exposed by a minute puncture, or if the tooth be aching 
at Ihe time of treatment. It may remain in for a day or 
two and then be replaced by a similar dressing; after 
which, if tenderness be lessened, a wool and mastic, or gutta- 
percha filling, may be inserted. In applying the carbolic 
dressing the end of an excavator should be rotated within 
a small piece of cotton-wool held between the thumb and 
fingers. The wool is thus rolled into a compact plug, 
the end of which may be dipped into a phial containing 
wool already saturated with carbolic acid. Thus only a 
small quantity of the latter is absorbed by the dressing, 
and indeed a larger application is undesirable as it is apt 
to excoriate the gums and cheek. Care should be taken 
that the plug is not inserted with so much force as to 
cause pain by pressure upon a nerve possibly exposed ; 
and sometimes when the application of carbolic acid fails 
to soothe an aching dental pulp relief may be readily 
obtained by the substitution for it of thymol or eucalyptin. 
The wool and mastic plug may bo inserted when the 
cavity has only slight tenderness. In applying it, the end 



of an excavator should be armed as before with a httle 
cotton-wool, which may be dipped into a strong solution 
of gum mastic in alcohol, after which a little dry wool 
should be w^rapped around the plug. This may be intro- 
duced into the cavity, v/hich has previously been washed 
out and dried, and maybe allowed to remain for a few days, 
after which it is apt to acquire an offensive odour and should 
be changed. The gutta-percha filling may be used under such 
conditions of the tooth and cavity as make a wool and mastic 
plug possible, and it is more durable and less absorbent 
of the fluids of the mouth than the last. Its durability 
will be greatly increased if, after washing and drying the 
cavity as before, a sharp excavator be carried round the 
v/alls of the cavity, removing the softened dentine until the 
underlying hard tooth structure is reached. . In so doing 
care must be taken to cause but little pain, and not to 
expose the dental pulp. To avoid this last, operate only 
on the edges of the cavity, leaving untouched on its floor 
the carious tissue. The gutta-percha, liaving been warmed 
over a candle flame, should be inserted while soft, and 
while only so hot that it may be applied to the back of the 
operator's hand without causing any pain. If the cavity be 
dry while it is being filled, and if such a stopping be in con- 
tact all round with hard walls, it may endure for some years ; 
but be it remembered that the durability of any stopping is 
proportionate to its faculty for excluding moisture. In this 
connection reference to gold, amalgam, and oxy chloride 
fillings is purposely omitted, such materials having no 
value save in the hands of those trained to their use. 
The employment of temporary plugs has, however, been 


treated of at some length, as such will often clo good service 
in allaying toothache, and preventing for a considerable 
time its return, by their exclusion of food, cold air, and 
hot and cold fluids from the sensitive surface. 

The caviti/ lanje and nerve exposed. — Under these circum- 
stances it may be impracticable to retain a temporary 
filling in the tooth, eitlier on account of its extreme sen- 
sitiveness and constant aching, or from the absence of 
such adjacent teeth, or overhanging walls to the cavity, as 
would prevent the plug from coming out during mastica- 
tion. Usually under these conditions extraction is the best 
course to adopt, but the health of the patient or other 
causes may prohibit this. The employment of arsenic is 
then indicated and should be thus applied. Equal parts 
of yellow soap and arsenious acid are to be well worked 
into a bolus, of which a pellet, as large as the head of a good 
sized pin, should be carried on an excavator into the 
bottom of the washed and dried cavity, as near as possible 
to the point of exposure of the pulp. The pellet may be 
held in situ by a plug of wool, w^hich should be removed 
after 24 hours and replaced wdth a wool and mastic .filling. 
One apjjlication of arsenic generally suffices to devitalize 
a dental pulp, but sometimes a second and smaller j)i6ce 
may be introduced into the tooth after two or three days, 
if it be found still sensitive to cold water from the syringe. 
The pain caused by the action of arsenic on a pulp is 
generally severe for three hours and commences within 
half an hour of its application. After six hours the pain 
has generally quite departed, and the condition of the tooth 
so changed that tlie ^oatient no longer dreads to inhale a 



deep breatli of cold air or to brush the teeth with cold 
water. Thus, at the expense of a temporary increase in 
such toothache as he may have already long suffered, may 
be gained complete relief, and the tooth, though its exist- 
ence may not be prolonged, will no longer remain a con- 
stant source of pain. In applying arsenic guard against 
allowing the soft pellet to be squeezed out of the cavity, 
wdiile the wool plug is being introduced, so that it is 
brought into contact with the surrounding gum. Thus 
much painful ulceration may be caused, and no beneficial 
action upon the aching dental pulp result. Guard also 
against using a pellet larger than the head of a good sized 
pin ; and also avoid its use altogether if decay has so far 
advanced that both walls, or the floor of the pulp cavity, 
are perforated so that the caustic should exert its destruc- 
tive influence upon the socket on the opposite side of the 

Caries in its Second Stage. 

The second stage of dental caries has been reached when 
the dental pulp, or any portion of it, has become gan- 
grenous, i,e,, dead and decomposing. Such a condition 
always results from decay when it is allowed to go on un- 
checked by natural or artificial means. -A natural limita- 
tion of caries sometimes occurs when the disease in its 
progress reaches a substratum of solid, well- developed, 
non-absorbent dentine. Then we find the floor of the 
cavity composed of hard dark ivory, which shows no 
tendency to softening. The artificial means employed 


to permanently arrest decay consist in excavating and 
filling the tooth with some imperishable material, or in 
cutting out the decayed tissue and carefully polishing the 
resulting surface. 

As a consequence then of the advancing caries the pulp 
becomes irritated, aches, and at last takes on a process of 
destructive inflammation, bv which after several hours of 
severe pahi its vitality is destroyed. Or this last condition 
may be reached more gradually and without any attack of 
severe pain. Here it may be noted that the vitality of a 
dental pulp may depart without any pre- existent decay and 
as a result of a generally depressed condition of the 
health ; or again it may be destroyed by a violent blow 
upon the tooth ; also by the action of arsenious acid em- 
ployed as before mentioned. The pulp having lost vitality 
will in a few weeks become putrescent, evolving the usual 
gaseous products of decomposition. The pulp cavity and 
the canals down each fang are now charged with a dark, 
viscid, fetid substance, from w^liich gas is constantly es- 
caping by any opening that may exist through the wall of 
the pulp cavity. This opening may be found at the bottom 
of the original cavity of decay, the result of the softening 
and destructive action of disease upon the dentine, or it 
may have been made artificially by the excavator of the 
operator. Such is the usual course of events : — the putre- 
faction of a dental pulp follows its death, unless, when 
arsenic has been used to induce this, a careful antiseptic 
treatment has been employed. 

To achieve this, to destroy a pulp and to protect it subse- 
quently from septic change, a minute attention to these 



Fig. 18. 

details is needed. The central cavity and the fang canals 
should be cleared three days after the application of arsenic 
of all devitalized organic filaments by inserting and with- 
drawing minutely barbed and antiseptically treated steel 

The fang canals and central cavity should 
then be dried with absorbent wool, and should 
be filled with filaments of wool saturated with 
carbolic acid. These should be tightly com- 
pressed within the tooth and allowed to re- 
main, while over them the permanent metal 
stopping is inserted. Thus the tooth may be 
made to last for many years, protected by the 
stopping from the advance of caries, and by 
the carbolised v/ool within it from the genera- 
tion of products of decomposition ; its vitality 
being sustained through the membrane cover- 
ing the cementum of its fangs. 

In the absence of such antiseptic measures, 
the death of the pulp, whether it come 
from the advance of caries, from depressed 
state of general health, from traumatic cause, 
or from arsenical action, induces putre- 
factive change within the pulp cavity. So 
long as the evolved gas can escape freely into 
the mouth no special symptoms, beyond a 
disagreeable odour of the breath, result. If, 
however, there be no such opening through 
the wall of the pulp cavity, or if one that has 
tor for removing existed, or has been made, be ^Dlugged up by 

devitalized den- . ., o n i i Il^^^ ^ i - ;i 

tal nerve. ^ particle of food, or by a lillmg oi any iimd 


inserted by the operator, v;o find at once, or within a 
few liours, a special and characteristic set of symptoms 
induced. The septic gas now collects within the pulp 
cavity, wdiere it is pent up unable readily to escape, and it 
may cause very severe toothache within half an hour of the 
plugging up of the hole if there be a small portion of the 
pulp still alive in one of the fangs. 

To the pressure of such clastic vapor thus suddenly ap- 
plied to a dental nerve of which the upper part was gan- 
grenous while the lov/er half was alive and sensitive, and to 
no other cause, can I attribute the severe pain which I had 
an opportunity of observing v\dtliin twenty minutes of the 
closure of an opening at the bottom of a carious cavity and 
leading into the pulp chamber from which a discharge was 
escaping from a semi-devitalized pulp. My opinion as to 
the mode in which pain was induced, and which always 
occurred within a short time of the aperture being blocked 
by particles of food, Vv^as confirmed wdien the tooth was 
subsequently removed, when on splitting it open the deeper 
lying parts of its nerve tissue were found to be perfectly 
healthy, those nearer the surface being gangrenous. 

If, however, the pulp be entirely gangrenous throughout, 
the pressure of the pent up gas serves to force out some of 
the softened and decomposed nerve tissue through the 
openings at the fang extremities into the socket of the 
tooth. The extrusion of such septic particles into proxi- 
mity with the healthy membrane lining the socket serves in 
most cases to induce more or less severe periodontitis, the 
cause of which, when it is localized around one tooth, is al- 
most invariably such as has been indicated, and it is a 


too til producing this- condition wliicli is popularly said to 
have '^ caught a cold." 

Periodontitis then is in almost all cases preceded by 
the death and putrefaction of the whole of the pulp 
and the extrusion of putrescent particles through the 
openings at the ends of the fangs. My own experience 
induces me quite to dissent from the views of those 
who hold that periodontitis may result from extension 
of inflammation from an inflamed pulp within a tooth to 
the healthy tissue outside its fangs, and, in support of my 
view, I may say that I have never yet met with periodon- 
titis, attended w^ith suppuration, around the fangs of teeth 
containing vital nerves. On opening into the pulp cavi- 
ties of such teeth as were causing periodontitis, their pulps 
have always been found to be in a decomposed state, and it 
is not evident how inflammatory action can extend, as has 
been asserted, from a tissue v/hich is itself already dead. 

We find further evidence in support of the cause here 
assigned for the production of periodontitis, localised 
around one tooth, in the fact that the condition may be 
almost invariably relieved in a few hours by drilling 
through the walls of the pulp chamber, and so allowing the 
gas to escape into the mouth rather than through the fang 
ends. If the opening so made be accidentally or inten- 
tionally closed in the course of a day or two, the gas which 
collects within the pulp cavity will again force its way into 
the socket through the openings of the fangs, and thus acute 
periodontitis may be once more set up. It may be noted 
that the rheumatic diathesis, mercurial treatment, or a 
traumatic cause, may produce sub-acute inflammatory 


change within the maxillary socket ; but this may he dis- 
tinguished from periodontitis arising from putrefactive 
change within a pulp cavity. The latter is at first locaUzed 
beneath one tooth, which is tender to pressure, often much 
decayed, and with pus escaping around its neck if the in- 
flammation in the neighbourhood of its fangs have pro- 
ceeded to the production of an alveolar abscess. 

Periodontitis thus caused by a process of putrescent 
inoculation may be acute or chronic. 

Syniptoins of Acute Fenodontitls, — 1. Dull, aching, contin- 
uous pain around a tooth which is usually much decayed. It 
must be noted, as has already been observed, that the pulp 
may die and decompose within a tooth that is in no way 
affected by caries ; so the presence of a cavity is not m- 
variable, and acute periodontitis may occur around the 
teeth of old persons, or of those in feeble health, or as a 
sequence to some injury that has devitalized a dental pulp. 
2. The tooth is slightly raised from its socket and so 
stands above the level of its neighboure and to the patient 
feels '' longer " than others. This comes from the swelling 
of the tissues inside the socket, whereby the conical fangs 
are slightly lifted out. From the same cause the tooth is 
rather loosened and may be rocked readily from side to 
side. 3. It is very tender on pressure and tapping, and 
this results from the communication of the force through 
the tooth to the highly sensitive and inflamed tissues 
around its fangs. In applying this test it is well to tap 
other teeth before the suspected one so that the element of 
nervousness may be excluded. 4. Our crucial test is to 
inject cold water with a syringe into the carious cavity, 


which, of course, as the nerve is quite dead, causes no pain. 
On cutting the decayed dentine very hghtly with a sharp 
excavator there is also no pain produced, since there is no 
longer sensation in the tooth. If the instrument be used 
at all forcibly the patient will complain, but this comes 
irom pressure of the tooth into its inflamed socket, and 
cannot be mistaken for the acute pain caused by cutting 
the dentine of a tooth affected by caries in its first stage. 
5. Around the fangs and within the socket a collection of 
pus soon forms, which discharges around the neck of the 
tooth, and with the formation of this Alveolar Abscess, as 
it is termed, relief from pain is generally experienced. 

The pain and inflammation may now subside, and the 
tooth may become fairly firm again, but Avhile it remains in 
the mouth it is likely to cause again similar trouble, or to 
act as a source of chronic periodontitis. 

Treatment of Acute Periodontitis. — As a rule it is best to 
extract the tooth causing the mischief ; but relief may 
usually be given in an hour or two by opening into the 
pulp chamber through its walls at [any part with an ex- 
cavator or sharp drill. By so doing the imprisoned gas, 
generated of the putrefaction that is going on within the 
tooth, is permitted to escape freely into the mouth, and so 
is no longer compelled to leak from the fang ends. The 
opening should be free, and kept patent by a filling of dry 
cotton- wool, loosely inserted and changed daily. This treat- 
ment may be applied to such teeth as it may not be desir- 
able to extract, and relief from pain may be almost certainly 
promised. The decayed temporary molars of children may 
be so treated (vide ante Chapter I.), also among adults we 


may thus relievo inflammation around a tooth Avhich may 
bo vahiable for appearance or mastication. Extraction, or 
opening into the pulp cavity, afford the only means of re- 
lieving acute periodontitis, and a slight consideration of 
the cause leading up to this condition will serve to con- 
vince of the absolute inutility of applying cscharotics or 
counter-irritants to the gum overlying the affected part. A 
popular impression is apt to prevail as to the undesira- 
bility of extracting a tooth around the fang of which acute 
inflammatory action, or an alveolar abscess, is existing. 
This it may be said is quite erroneous. With the removal 
of the tooth that is the cause of the periodontitis, wdiether 
the latter be attended Avitli the formation of matter 
or not, the pain and swelling in and around the alveolar 
structures wall soon subside, and, if extraction be deemed 
desirable, the operation should be effected without any 
delay. Not infrequently a good deal of dull aching pain 
wdth a sense of tension and throbbing w^ithin the socket will 
follow the removal of the tooth. This may endure for two 
or three days unless relief be given by occasionally raising 
from the site of extraction with the point of an excavator 
the firm blood-clot beneath which sanguineo-purulent fluid 
is apt to collect and be pent up within the inflamed socket. 
This is a point of some importance and the patient, if un- 
able to obtain medical assistance daily, should be instructed 
to perform the operation for himself, using for the purpose 
the x^oint of a pair of scissors or the end of a sharpened 

Symptoms of Chronic Fcriodontitis. — The inflammatory 
action set up around the fangs may take a chronic form, 


tliougli the cause is the same whether the periodontitis 
be acute or chronic, and rehef may be given by similar 
treatment in both cases. The gaseous products of decom- 
position from the interior of the tooth leaking through 
the fang ends, with the j)^i'^"ilei^t secretion that forms 
around it wdthin its socket, escape through a sinus which 
usually o]3ens through the outer alveolar plate and the 
gum covering it. The orifice of such sinus is marked by 
a small papilla, or gum-boil as it is termed, from which 
pus may be often found escaping in small quantities. The 
gum- boil may at times be found on the palatine mucous 
membrane over the inner fang of an upper molar, but 
as a rule it is placed on the outer surface of the gum. 
This condition may endure for several years, the gum- 
boil alternately coming and going, and the tooth slightly 
loosened in its socket and occasionally tender on pressure. 
An alteration in the colour of a tooth containing a decom- 
posed pulp is generally evident in the course of a few 
weeks from the time at which the latter became devitalized. 
The coffee- coloured fluid within the pulp chamber fills the 
dentinal tubules, stains the dentine, and its dark tint is 
apparent through the semi-translucent enamel. If then 
any tooth in the neighbourhood of which there is a gum- 
boil, and which is a little loose, and occasionally rather ten- 
der, shows on examination by daylight a darker tint than its 
neighbours we may safely conclude that its contained pulp 
is decomjDOsed, and that a condition of chronic periodontitis 
is established around its fangs. In such a condition we 
often find a tooth containing a large stopping under which 
the pulp has died and decomposed, or in which the pulp 


at the time of stopping was dcvitalizod l)y the operator 
Avitli the aid of arsenic. It should be noted, however, tliat 
if such antiseptic precautions as liave already been men- 
tioned be taken after the use of the latter there is but 
Httle fear that putrefactive changes within the tooth, and 
chronic periodontitis around its fangs, will be the sequel to 
its stopping. Such a mishap may generally bo attributed to 
the neglect of such precautions, or to the imperfect manner 
in which they have been carried out. It is not unusual to 
find a tooth, which has for some years caused in the manner 
described a slight irritation within its socket and a gum- 
boil over its fang-ends, becoming eventually quiet and ceas- 
ing to trouble by the generation and extrusion of putrefac- 
tive products from its interior. Frequently, however, such 
teeth become gradually loosened and are shed, or by their 
becoming a source of pain their extraction is necessitated. 
Then their fangs are found to be rough and partly eroded 
towards their extremities, around which also are adherent 
shreds of fibrous exudation. 

Treatment of Chronic Periodontitis, — Chronic periodontitis, 
whether it be caused by a carious tooth ; by a tooth sound 
as regards decay ; or by a tooth in which a stopping has 
been inserted, may be relieved by drilling or excavating an 
opening through the walls of the pulp chamber, or through 
the stopping as the case may be. Such a hole may be 
minute, and may be drilled through the outer side of its 
fang on a level with the edge of the gum, an operation to 
which the name of rhizoJontropJnj has been given. Thus a 
vent is afforded to the imprisoned gas, the irritation within 
the socket is usually allayed, and the gum -boil disappears 


and is absent so long as the opening into the pulp cham- 
ber remains patent. By a careful introduction of car- 
bolic acid or Condy's fluid into the fangs, if access can be 
obtained thereto, the putrefactive change may be i^artially 
arrested ; but such an operation can at the best be only im- 
perfectly performed, and the dentinal tubules, charged as 
they are with fetid organic matter, remain inaccessible to 
the agents and instruments of the operator. If the x^nlp 
has but recently died and decomposed these measures 
should be adopted and have great value, but if the stain- 
ing of the tooth shoY/s that the septic change is of long 
standing they cannot be expected to prevent further putre- 
factive change within the tooth. Care should be taken when 
introducing Condy's fluid on the dressing of wool into a 
fetid fang lest any decomposed organic matter be driven be- 
fore the x^iston through the opening at the fang end. Such 
a mishap has frequently resulted in the treatment, which 
was designed to relieve chronic periodontitis, becoming in it- 
self a cause of acute inflammatory action within the socket. 

Cakies in its Third Stage. 

If decay advance unchecked the crown of the tooth 
disappears, leaving sharp spiculae of enamel that are apt, un- 
less filed down, to excoriate the cheek or tongue. With the 
disappearance of the crown decay may be said to have 
reached its third stage, and nought now remains of the 
tooth save the fangs, the dentine of which has become ca- 
rious and softened, and which contain the debris of dead 
and decomposed nerve tissue. Such stumps may remain 


for years without causing any trouble, but frequently tlioy 
setup a condition of chronic inflammation, as the result of 
which they may become rough and eroded and more or 
less enlarged or c.wstosed, as it is termed. Moreover, by an 
exudation around them of inflammatory lymph, they may 
be glued into their sockets so tightly that their extraction 
becomes at times no easy task. The difficulties met with 
in the removal of such stumps arise from three causes : 
1. the glueing of the fang into its socket which prevents 
the ready introduction of the blades of the forceps ; 2. the 
hollowed condition of the interior of the fang which induces 
its walls to collapse as soon as the instrument is forcibly 
closed upon it ; 3. the exostosed condition of its surface, 
which is often caused by chronic periodontitis, and by which 
it is firmly rivetted, as it were, into the maxilla. Pain, 
when it is caused by decaying stumps, is of a neuralgic 
nature, not located around its exciting cause, but intermit- 
tent and flying over the side of the face and head, and it is 
increased by hunger, fatigue, or other depressing cause. 
As to the propriety of removing such fangs there can be no 
question. With their removal the neuralgic trouble will 
vanish, and it may be confidently stated that facial neural- 
gia has almost invariably a dental cause. Stumps, if 
quiet, may be disregarded, since they may be of a certain 
use in masticating food ; but, if it be thought desirable that 
artificial teeth should be worn, it is generally well to ex- 
tract all such stumps as are causing any local or nervous 
irritation before taking the models to which the frames are 
to be constructed. 

It should be noted that chronic inflammatory action or 


irritation, wlien produced by any of the six lower molars or 
their fangs, is apt to prove the cause of the two following 
well marked conditions, which, though they may be caused 
by other teeth, are not often associated with disease of any 
but the lower molars. 

1. Closure of the jaws, — This rarely results from irritation 
save that which is caused by a second or third lower molar, 
and more often comes from the latter than the former tooth. 
Inflammatory exudation, slowly organized into fibrous 
bands, may have slowly formed around the temporo-maxil- 
lary articulation on the affected side, and by its gradual 
contraction may have so reduced the opening into the 
mouth between the incisor teeth that the introduction of 
solid food may have become almost impossible. Under these 
circumstances the j)atient should be well anaesthetised and 
the mouth forcibly opened with the aid of a powerful screw 
gag {vide fig. 30) placed between the bicuspid teeth. Pres- 
sure should bear upon these rather than upon the incisors, 
since the latter may be broken or dislocated by the required 
force. The ligamentous adhesions around the articulation 
being thus stretched, the dental cause of the mischief may 
be searched for, and should be entirely removed. For the 
after treatment of such cases a daily separation of the teeth 
should be gently and gradually effected with the aid of the 
screw gag, and will serve to restore in a week or two the 
original mobility of the jaw. 

2. Fistulous opening through the cheek, — This rarely pro- 
ceeds from any but the lower molars, and of these the 
first molar is more apt than the second or third to prove 
the cause. It may be apprehended w^hen the cheek over- 


.lying the seat of periodontitis, whether this be acute or 
chronic, is found to become glazed, reddened, and adherent 
to subjacent structures. No time should lost in 
extracting the tooth or stumps that appear to be causing 
mischief, and thus by timely action the disfigurement may 
be averted. The fistulous opening when once established 
may remain for years a channel through which puru- 
lent fluid, secreted around the diseased fangs, occasionally 
escapes. After a time the discharge may cease by natural 
causes; but the extraction of the stump, which being 
usually glued into its socket is sometimes difficult of re- 
moval, will at once cure the condition, if it be not so far 
advanced that necrosis of a portion of maxilla has been 
induced. If this last exist the healing must of course be 
delayed until the dead structure has been thrown off or 
removed, but always an unsightly pucker in the face will 
mark the site of the old fistulous opening. 



Chapter VI. 


Odontalgia, Periodontitis, Gas Pressure on the Ner\^, 


Pain in or around a tootli is, as a rule, one of the at- 
tendants upon its decay at some stage of the disease, and 
usually takes one of the following forms. 

I. Odontalgia, or the pain that accompanies the first stage 
of decay (see Chap. V). This varies in severity, is inter- 
mittent, and at times comes on in sharp paroxysms. It 
is located usually in the aching tooth, but, if a lower 
wisdom tooth be affected, it may fly up into the neigh- 
bourhood of the ear. It is increased and induced by hot 
and cold fluids, cold air, pungent or sweet food, and pres- 
sure of particles into the carious cavity during mastica- 
tion ; while, as its cause, is always to be found some tooth 
of which, the crown is more or less damaged by decay or 
mechanical violence, and of which the dental pulp is in a 
vital, highly sensitive, and irritated condition. 

The treatment of odontalgia must vary with the local 
condition producing it. If decay be not far advanced, and 
the nerve not exposed, or exposed by only a small aper- 
ture, the cavity should be syringed out with warm water, 
and should be plugged with a dressing of wool and carbolic 
acid {see Chap. V). Thus the irritated pulp is soothed, 


and XDrofcected by a non-conductor of heat from thermic and 
other influences. The wool may be changed daily, or may 
be replaced in a few days by a filling of gutta-percha. 
Should the cavity be large and [the pulp freely exposed it 
will probably be necessary to destroy the latter with the 
aid of arsenic {see Chap. V), or to extract the tooth. 

II. That which attends Acute Periodontitis, — Such pain is 
constant y as distinguished from the intermittent pain of 
odontalgia. It is at first dull, but becomes more severe as 
the inflammation increases,- and endures often until a 
discharge of pus takes place, which wells up around the 
neck of the tooth from the alveolar abscess that may have 
formed within the socket around its fangs. With the 
formation of matter a sensation of throbbing is experienced 
within the maxilla, and considerable swelling of the soft 
parts around the seat of mischief is then noticeable. The 
tooth becomes very tender to pressure or gentle tapping, is 
raised from its socket, and so loosened that its crown may 
at times be readily moved laterally to and fro, but it is 
not sensitive to hot or cold fluids. Its pulp cavity and fang 
canals contain always dead and decomposed nerve tissue, 
from which septic particles have been extruded into the 
alveolar sockets through the orifices at the ends of the fangs 
by expansion of gaseous products of putrefaction pent up 
within the pulp cavity [see Chap. V). A tooth thus cir- 
cumstanced is usually found to be much decayed, but, as 
before mentioned, periodontitis may be induced by the 
action of one in which the pulp has lost its vitality 
from causes other than caries, as from a blow, or from 
general ill-health. To relieve the pain of periodontitis 



the pulp cavity should be opened with a drill or an exca- 
vator, so that the pent up gas may escape, or, if the 
mischief be far advanced, the tooth should be extracted. 
The latter operation, as before said, may be performed at 
any stage of the disease ; indeed, the more severe the in- 
flammatory action may be, the more needful it becomes to 
extract the tooth. 

III. That caused by gas j)i*essure upon a sensitive portion of 
a dental pulp, — Such pain is most intense, constant, of 
several hours in duration, and located strictly within the 
affected tooth. This will be found to contain s^;?^^-gan- 
grenous nerve tissue ; that portion of the latter situated 
within the fang canals being still vital and sensitive, while 
that occupying the pulp chamber has lost vitality, is gan- 
grenous and evolving gaseous products of putrefaction. 
These, pent up within the sealed pulp chamber, unable \'j 
discharge themselves into the mouth, produce by their in- 
creasing pressure on the nerve filaments still retaining 
sensibility the intense pain that accompanies this condition, 
which may endure until the vitality of the whole of the 
nerve has been destroyed. The tooth thus affected is 
sensitive to neither heat nor cold, since its nerve is par- 
tially dead ; nor is it tender on tapping, since as yet no 
periodontitis exists within its socket. Belief may be in- 
stantaneously afforded by opening with drill or excavator 
into the pulp chamber, through the floor of the carious cavity 
which generally exists, and by so doing the gaseous tension 
within the tooth is at once relieved. The opening should 
be kept patent by a plug of cotton wool, loosely inserted and 
changed daily. From what has been already said it may 


readily be understood that the death, and subsequent pu- 
trefaction of the ichole of the dental pulp thus brought about 
may, in the course of a few weeks, produce a condition of 
periodontitis within the alveolar socket. 

IV. Alveolar and Facial Neuralgia. — This is variable in 
degree, becoming more severe when the general health is 
disturbed, and after bodily fatigue and want of food. It flies 
up the side of the face, into the neighbourhood of the ear, 
or downwards towards the shoulder and arm. There may 
in almost all cases be found the stumps of decayed teeth, 
which should be completely removed if the neuralgic symp- 
toms are persistent, and it may be noted that most cases 
of what is tevmei face -ague and tic douloureux haye, as their 
exciting cause, a dental condition such as that described. 

The four preceding conditions 'are those usually accom- 
panying pain in and around the dental structures, and such 
admits of ready relief if its cause be recognised and the 
appropriate remedy adopted. 


Chapter VII. 

Wearing down of the Teeth from Friction of Mastica- 
tion. Hunter's Denuding Process. Fracture and 
Dislocation of a Tooth from Violence. 

Towards middle life the cutting edges of incisors, and the 
grinding surfaces of the masticating teeth, show signs of 
wearing down, and the rapidity of such action is dependent 
upon the density of the tooth structure, and upon the 
nature of the food. Among savage races, who live mostly 
on coarse badly prepared materials, we see such extensive 
attrition that the pulp cavities would be speedily opened 
into, did not a develo|)ment of secondary dentine within 
the pulp cavity and adherent to its walls prevent such a 

It is also not^unusual to find among middle aged per- 
sons a deep horizontal well polished groove, reaching 
almost into the pulp chamber, across the outer surfaces 
of the necks of incisor, canine, and bicuspid teeth. This 
condition, to which the name of Hunter's denuding j^^^ocess 
has been applied, results from the friction of the tooth- 
brush acting upon the softer cementum of the neck of the 
tooth which has become exposed by the commencing re- 
cession of the gums. From this last catise the necks oi 


the teeth arc towards middle hfe frequently laid bare, and 
their less durable structures arc liable to be thus damaged 
by a mechanical cause, aided by the solvent action of the 
fluid of the mouth. 

The surface tenderness which is often associated with 
this action may be relieved by a frequent application of 
eau de Cologne upon wool ; but if there be a deep cup- shaped 
cavity in the grinding surface of a molar, or a groove upon 
the neck of an incisor opening almost into its pulp^cham- 
ber, it may become necessary to insert a metal filling in 
order to prevent further and more serious damage to the 
tooth. Moreover, all ra^Didly cutting tooth-powders, such 
as charcoal or pumice powder, should be at once discon- 
tinued, and a soft brush be used with soap and chalk. 
These last only should indeed be em|)loyed in all cases, 
and if used twice daily will be quite effective in keeping the 
teeth well polished. 

One or more teeth may be fractured by a blow acting 
directly upon the damaged organs, or indirectly through 
the sudden closure of the lower teeth upon the upper, as 
when a heavy fall is sustained upon the chin in the hunt- 
ing field. The rough fractured surface may be smoothed 
down with a fine file if the damage be but slight, and sur- 
face tenderness may be relieved by an application of eau 
de Cologne or nitrate of silver. If the pulp cavity be 
broken into it may be necessary to destroy the nerve 
with arsenic, and subsequently to fill the tooth or to file it 
down to a level with the gum ; or to extract its fang pre- 
paratory to the insertion of a plate carrying an artificial 


An incisor tootli may be partly or entirely dislocated by 
violence. It is well in such cases to replace it and by a 
careful moulding of gutta-percha, softened in warm water, 
around it and its neighbours, to retain it in situ, in the 
hope that it may again become firm in its socket. This it 
will very frequently do, but the violence to which it has 
been subjected generally destroys its dental-pulp, which 
by subsequent decomposition is liable to induce periodon- 
titis in the course of a few months. For this last the 
remedy, as before pointed out, is to drill a small opening 
through the neck of the tooth into its pulp chamber (see 
Chap, v., rliizodontrophy) , 


Chapter VIII. 


Conditions Necessitating Extraction. General direc- 
tions AS to the Position of Operator and Patient. 
Concerning the Application of Forceps. As to the 
Extraction of the Tooth. Accidents during 
Extraction. A List of Instruments needed for 
Extraction. Forceps, their General Characters 
AND Various Forms. The Elevator, its Description 
and Mode of Using. The Screw Extractor. 

Attention to some practical points in connection with this 
subject is necessary to the medical practitioner, who, 
though his dental practice should, have a wider range, is 
likely to be more often called upon to use the forceps than 
to perform other dental operations. He may be required 
to relieve irregularity and overcrowding among the per- 
manent teeth of his young patients by the judicious re- 
moval of one or more dental organs. He may find 
extraction to be the only means by which he can cure 
the toothache for which his patient has consulted him, 
and he will be called upon to adopt this treatment when, 
from the necessities of the case, immediate relief from severe 
pain is urgently demanded. This last may be required 


when extensive caries, or fracture from direct or indirect 
violence, has laid bare an aching dental pulp ; or when 
acute periodontitis is producing alveolar abscess. He will 
find it absolutely necessary to extract a diseased lower 
wisdom tooth which is causing closure of the jaws through 
the contraction and rigidity it may have induced around a 
temporo -maxillary articulation. Moreover, to cure a fistu- 
lous opening through the cheek, or to prevent its occur- 
rence when threatened, nothing will suffice but the 
complete removal of the lower molar which he will pro- 
bably discover to be the cause of mischief. He may be 
required to take out a loose temporary tooth the fangs of 
which, sharpened by partial absorption, are ulcerating 
through the gum and excoriating the cheek or lip ; extrac- 
tion may be needed by a decayed lower molar v\^hose 
ragged edges are threatening to produce malignant disease 
of the tongue ; or for the cure of - epulis some decayed 
stump, underlying the tumour, may need removal. As 
the teeth become loosened by the absorption of alveolar 
process and recession of gums that accompany other senile 
changes, extraction will from time to time be required to 
prevent them from proving a hindrance to mastication. 

Th6 foregoing are the most frequent conditions under 
which the use of forceps is indicated, though doubtless from 
time to time their employment will be required from other 
causes. To apply them effectively it is necessary to place 
the patient in a solidly made chair with the back sufficiently 
low and so cushioned that, if the removal of an upper 
tooth be required, the head may be readily thown back and 
supported. The head and hand of the operator should 


never be allowed to intercept the light wliich slioukl fall 
directly upon the tooth. When an upper tooth on cither 
side is to be extracted, he should stand with feet well 
separated by the ri(jht hand of his patient; he should stand 
immediately heJdnd the latter and leaning over his head 
when about to take out a lower tooth on the right side ; and 
when extracting any lower tooth on the left side the opera- 
tor should place himself by the left side of his patient. 
The attitude of the operator should be easy and uncon- 
strained, so that his power may be exerted to the best 
advantage. With this in view the operating arm should 
be held fairly close to the side that its movements may be 
well regulated and under control ; the head of the patient 
raised or lowered ; the chin thrown upwards or depressed ; 
and the head always so turned towards the operator that 
his forceps may have easy access to the tooth. If it be an 
upper tooth that is to be extracted his left hand must 
be used to steady the upper maxilla during application of 
the forceps, and to aid the extraction by providing an oppos- 
ing force to the traction of the instrument. To effect this 
he should firmly grasp with fingers and thumb the alveolar 
process on either side of the tooth he is about to remove. 
If the tooth be in the lower jaw the left hand should be 
used to prevent all rocking and depression of the inferior 
maxilla by rigidly securing it between the fingers and 

In applying forceps to a tooth with a view to its extrac- 
tion the operator should determine to insert their blades as 
deeply into the socket and as far up the fang as is practic- 
able. An exception to this holds good when the removal of 


a temporary molar is demanded, since the crown of the 
underlying permanent bicuspid may be grasped by the in- 
strument if this be used too vigorously. In the application 
of forceps these points should be regarded. 1. The tooth 
should be grasped very lightly between the blades of the in- 
strument in order that the latter may travel freely up its 
fang. 2. The forceps should be pushed freely and vigor- 
ously home. 3. During this process the instrument should 
receive the slightest possible rotation on its long axis. This 
should hardly amount to more than a tremulous movement, 
but it suffices to convince the operator that the blades are 
not gripping the neck of the tooth so tightly as to prevent 
them from travelling up it. 4. The long axis of the blades 
of the forceps should be[^continuous with or in the same 
direction as the long axis of the tooth. If this be disregarded 
the margin of the blades may impinge upon a neighbouring 
tooth, which by its resistance may greatly hamper the opera- 
tor while performing extraction. This precaution is very 
necessary when an upper bicuspid has to be removed. 5. 
The eye of the operator should be fixed upon the tooth and 
it should never be lost sight of throughout the operation. 

The neck of the tooth being thus securely and firmly 
grasped, extraction should be effected by steady and contin- 
uous traction. Combined with this should be partial rotation 
on its long axis, if it be a single fanged tooth, as an upper or 
lower incisor, canine, or bicusi3id, with also a slight amount 
of rocking or lateral movement applied judiciously and with 
great caution. Be it born in mind that the risk of break- 
ing a single fanged tooth is greatly increased when this 
rocking movement is applied, but in some cases it is quite 


necessary to adopt a certain amount of it. If it bo an 
upper or lower molar, the tooth should be freely rocked in- 
wards and outwards wdiile forcible traction is being em- 
ployed, and with such teeth any rotation upon the long 
axis is of course prohibited by the arrangement of their 

There are certain untoward occurrences, by no means 
uncommon in tooth extraction, which must be noted as 

A. The tooth to which forceps are applied may break. This 
accident usually results from one of the following causes. 
1. The long continued progress of decay may have almost 
entirely softened the dentine of which its fangs are com- 
posed. Added to this may be the glueing of their exteriors 
into their sockets by inflammatory exudation before re- 
ferred to {see Chap. V.) These conditions prevent the blades 
of forceps from travelling down, and favour the collapsing 
of the walls of the stumps as soon as pressure is brought to 
bear upon them. In such cases it is well to commence by 
using the elevator to partially dislodge them, and the forceps 
may then complete their removal. In this state do we often 
find a carious lower molar with which a fistulous opening 
through the face is connected. 2. The fangs may be con- 
siderably curved and clinging tenaceously to septa of bone or 
to fangs of neighbouring teeth. 3. The fangs may have, as 
the result of chronic inflammatory action, become enlarged 
or exostosed, and so rivetted into the alveolar process. 
4. The dentine may have as the result of senile changes 
become almost as brittle as glass, and on this account it is 
well to be on one's guard when dealing with the teeth of 


elderly j)ersons. From any of these causes a tooth or 
stump may break, and blame in many cases is not to be 
attributed to the operator if it do so. He should al- 
ways, before applying his forceps, ascertain the mobility 
of the tooth in its socket by rocking it carefully and 
slightly to and fro with a strong excavator resting against 
the inner or outer wall of its crown. If fracture occur 
during extraction, he should wipe away with a plug of 
absorbent wool on the end of an excavator any blood 
which may conceal the surface of the stump, and then 
attempt its removal with a finer or narrower instrument. 
If he now fail after a reasonable attempt, let him desist, 
since a prolonged operation serves but to exhaust his 
patient, and prevents his own success in any subsequent 
operation he may enter upon. If, as the result of the fracture, 
there be apparent a vital and intensely sensitive exposed 
dental pulp, this may be removed as completely as possible 
by passing down the fang a finely barbed nerve extractor 
[vide fig. 18, Chap. V). The stump, if it cannot be removed, 
may be allowed to remain with the probability that it will 
now give no more trouble, since the nerve which was pre- 
viously aching has been removed, and being healthy and 
free from septic change it is not likely to set up perio- 
dontitis. If the motive for the attempted extraction be the 
relief of periodontitis, this condition will be relieved by 
the complete opening of the fang canals and the free 
escape thus given to imprisoned gas by the breaking off 
of the crown of the tooth. The patient may be further 
consoled by an assurance that after a year or two the pro- 
gress of absorption both of fang and alveolar process will 


probably render the removal of the broken stump compara- 
tively easy. 

B. While extracting a lower molar an upper incisor may 
be broken by the back of the lorceps. This results from 
the sudden parting of the tooth from its socket after a pro- 
longed effort has somewhat exhausted the muscular power 
of the operator. Guard against this by keeping the opera- 
ting arm well under control, and by intently watching for 
the moment when the tooth is about to sever connection 
with its socket. 

C. A tooth may be taken out other than that which it was 
designed to extract. This can result only from want of 
care, and should be guarded against by closely watching 
the forceps and the tooth- they are enclosing throughout 
the whole operation. During hurried extractions under 
nitrous oxide this misfortune is liable to occur, when the 
instrument is applied within a moment of the removal of 
the face-piece by an operator whose haste and nervousness 
may prevent him from duly observing the parts with which 
he is dealing. 

D. The alveolar process may be fractured, and indeed it 
is very common to find a small fragment of the outer al- 
veolar plate adherent to the fangs of a molar after it has 
been removed. More than this has not happened within 
my experience, but a separation of the intermaxillary bone 
from the superior maxilla during removal of an upper in- 
cisor, and of transverse fracture of the ramus of the lower 
jaw while a lower tooth was being extracted, have been re- 
corded by Mr. Salter. The accidents occurred in both cases 
to operators who possessed such skill and knowledge as to 


make it certain the like may in some conditions be inevit- 
able. Apart from this, however, must be regarded the 
breaking off of the tuberosity of the upper maxilla during the 
the use of an elevator for removal of an upper wisdom 
tooth. For extraction of this last, forceps should be used, 
and the powerful leverage afforded by the former in- 
strument served in a case that came under my notice a 
few years since to break away, with the upper third molar 
which was extracted, a mass of spongy bone in size as large 
as a walnut. 

E. The gum may be lacerated during removal of a lower 
second, or third molar, through its occasionally strong ad- 
hesion to the neck of the tooth. If this be the case a 
scalpel should be used to divide it before the molar is entirely 
withdrawn from its socket. 

F. The tongue or cheek may be punctured, and a large 
blood vessel thus opened, by the slipping of an elevator. 
The firm pressure of the end of the first finger of the 
operating hand upon the blade within one quarter of 
an inch of its extremity, at the moment of introduction, 
and then, as it is being thrust into the alveolus, upon the 
tooth to be taken out, or upon its fulcrum, will suffice to 
prevent this mishap. 

G. The extracted tooth or stump may slip from the 
grasp of the instrument and passing into the trachea may 
cause much trouble. This is an accident which those 
operating upon an anaesthetised patient should guard 
against by carefully folding a mouth-napkin within the 
mouth behind the teeth or stumps that are about to be 


H. Persistent liDemorrliage after extraction, or coming on 
within a few hours of the operation, may need prompt at- 
tention. The firm blood clot which may often be found 
concealing the bleeding socket and its neighbouring teeth 
should be vigorously wiped away with a plug of wool on an 
excavator; a strip of dry lint, J of an inch wide and about 6 
inches long, should then be plugged into the socket, being 
condensed tightly and carried down completely to its bottom, 
with the aid of the excavator. Over the plug should be ap- 
plied a^compress of lint, and on this the jaws should be kept 
tightly closed for a few hours. In this way the bleeding 
may with certainty be controlled, and though the compress 
may be changed daily, the plug within the socket should 
remain undisturbed for three or four days. In arresting 
haemorrhage under these circumstances dry lint will be found 
more effective than that moistened with any fluid styptic, 
such as Tinct. Ferri Perchlor. 

A complete equipment of instruments for extraction 
should include eight forceps, one elevator, and one screw 
extractor and drill for the latter, and with less than these 
a practitioner will hardly be enabled to deal with all cases 
presenting for treatment. 

The eight forceps should have these characters. Their 
handles should be strong, unyielding, and quite without 
spring, which tends to prevent an operator from judging ac- 
curately of the amount of pressure he is applying to a tooth. 
Their joints should be strong, and without any play, which, 
if it occur after considerable use, should be remedied by 
careful tightening up of the central rivetted screw. A loose 
joint causes much inconvenience during extraction, and 


while wrenching the fangs from their sockets, since it allows 
the blades to slide to and fro over the sides of the tooth. 
Care should be taken that water, when cleansing the for- 
ceps, does not enter its joint, and the latter should be 
occasionally oiled that it may work freely and without any 
rigidity. The blades should be well tempered, being neither 
so soft as to bend or splay out at their edges, nor so hard 
as to chip or fly. Also the space between them, towards 
the joint, should be wide enough to enable them to close 
firmly upon the neck of a tooth without coming in contact 
with its crown. The stock of forceps should consist of the 

Fig. 19. 

Upper incisor and canine forceps - 

One pair of wppe^' incisor and canine forceps. It will 
be seen that the long axis of the handles of these is 
not quite continuous in the same line, but is set at a 
slight angle with the long axis of their blades. In applying 
them to an upper front tooth they should be so placed that 
their handles incline towards the patient's chin rather than 
from it. To summarize the directions before given, remem- 
ber in their application to force them well up the neck of 
the tooth. Ensure this by grasping the latter lightly, 
regulating the pressure by firmly pressing the ball of 
the thumb of the operating hand into the space between 



the handles. Also while forcmg them up withm the socket 
give them a slight tremulous movement, or one of partial 
rotation upon their long axis, amounting to about jy\j ^^ ^ 
ch'cle, so that the sharp cutting edges of their blades shall 
sever the membranous connections between the fang and its 
socket. Extraction will be performed by steady continuous 
traction, increasing gradually in amount, during which the 
fang, being firmly and cautiously grasped, may be slightly 
rotated on its long axis. Any rocking movement, to and 
fro, or in an antero-posterior direction, is, as before men- 
tioned, here injudicious. Efforts in this direction should 
at any rate be applied with much circumspection and only 
when traction with rotation does not promise to produce the 
desired result. The operation should not be hurried, and 
if the fang show signs of giving way the grasp of the in- 
strument should be relaxed and it should be thrust more 
deeply into the socket. What is applicable to these forceps 
may be held to apply equally to those intended for the re- 
moval of lower front teeth and of upper and lower bicus- 

Fig. 20. 

Upper bicuspid forceps for either side. 

One pair of upper bicuspid forceps for either side. The use 
of these should be confined to the extraction of upper 



bicuspid teeth, of entirely detached molar fangs, and occa- 
sionally of upper wisdom teeth. They should never be 
employed for the removal of badly decayed upper first or 
second molars, whose fangs are still imited. 

Fig. 21, 

Forceps for lower incisors, canines and bicuspids. 

One pair of forceps for lower incisors^ canines and bicuspids. 
These are of much service also in the extraction of greatly 
decayed lower molars, which threaten to be fractured if 
grasped by the ordinary lower molar forceps. With the 
former, one fang, usually the anterior, may be grasped 
deeply in the alveolus and removed separately ; or, as often 
happens, with the posterior fang attached to it. It should 
be noted that the second permanent or twelve year old 
molars are more rigidly fixed in the maxillae than are the 
first or six year old molars. It follows therefore that the 
former, when greatly decayed, are more liable than the 
latter to fracture when the ordinary molar or double for- 
ceps (to be spoken of later on) are applied to them. For 
extraction therefore of second permanent molars, the lower 
bicuspid, or, as they are sometimes termed, stump forceps, 
are of considerable value. When one fang has been de- 


tached and removed, but little difficulty will usually be 
encountered in taking out also the remaining fang. 

One pair of forceps for upper right molars. The tang pro- 
jecting from one blade is inserted between the two outer 
fangs, and the neck of the tooth being rigidly grasped, 

Fig. 22. 

Forceps for upper right molars. 

well within the socket, should be steadily rocked inwards 
and outwards while forcible traction is being exercised. 
No movement of rotation is admissible during extrac- 
tion of upper and lower molars, owing to the arrangement 
of their fangs. An upper wisdom tooth, if not too firmly 
rooted, may be readily removed by upper molar, or stout 
bicuspid forceps. If it be very rigid and unyielding, it is 
well to commence by moving it slightly in its socket with 
the aid of an elevator, which should be thrust in betw^een it 
and the second molar. The use of the elevator in this 
situation requires considerable care, owing to the liability 
thus encountered of breaking away the tuberosity of the 
superior maxilla, and the extraction of the tooth is to be 
completed with the forceps. 



One pair of forceps for upi^er left molars. The tang pro- 
jecting from one blade is inserted between the two outer 

Fig. 23. 

Forceps for upper left molars. 

Ofie jjair of loiver molar forcej)s for either side of the mouth. 
Each blade presents a projecting tang which should be 
inserted between the two fangs of the tooth. If the latter 

Fig. 24. 

Lower molar forceps for eitlier side of the mouth. 

be fairly solid and resisting these should be used in prefer- 
ence to the lower stump, or single fang forceps, since they 
afford a more secure and complete grasp of the tooth. As 
the long axis of lower molar teeth is frequently directed 
upwards and somewhat inwards, the operator should 
guard against depressing the handle of the forceps too 



freely, by doing which he may at any time readily break off 
the crown of the tooth. If the lower molar be at all 
tilted inwards, he should aim at lifting it upwards and in- 
wards at the time he is engaged in rocking it freely inwards 
and but slightly outwards. 

Fig. 25. 

Upper stump forceps. 

One pair of upjjer stump forceps. These are of use when 
searching for deeply buried single fangs, and being of 
somewhat delicate construction should not be too severely 

Fig. 26. 

Lower stump forceps. 

One p)air of lower stump forceps. These resemble those 
in fig. 21. Their blades, however, are somewhat longer, 
are more delicate, and close more completely at their cut- 
ting edges. 

The Elevator should be strong and unyielding. Its 
length, inclusive of handle and blade, should be from five 
to six inches. The handle should possess a smooth broad 


end, that the palm of the hand may not be injured when 
using it forcibly. The blade should be two inches long ; 
and, for its lower inch, it should be flat on one side, 
convex on the other, and one quarter of an inch wide. 
Its extremity should possess a sharp cutting edge, and be 
neither pointed nor flat, but gently rounded. All spear 
and spoon shaped elevators are to be avoided ; also, the in- 
strument should be straight throughout, without curve or 
bend of any nature. 

The elevator is of great value for extraction of lower 
wisdom teeth and of firmly implanted stumps. It can be 
employed only when there is a vacant space, or portion of 
maxilla free from any stump or tooth, immediately adjacent 
to the tooth for removal of which it is to be used ; and 
for extraction of upper wisdom teeth it is rarely to be used, 
owing to the liability of fracturing the tuberosity of the 
upper maxilla. It should be inserted forcibly into the 
alveolus, alongside and in front of the tooth on which it 
is to operate, with its flat face adjacent to the latter, and 
its convex side in contact with the fulcrum. Its point 
should be directed during insertion downwards and in- 
wards, so that the long axis of the instrument is about 
half way between the horizontal and the perpendicular. 
The elevator can be used effectively only if there be some 
strong, firmly implanted tooth, against which it can rest, 
as on a fulcrum ; and if it be remembered that the ele- 
vator is used only as a lever of the first order, the need for 
this rigidity in its fulcrum must be apparent, since the pres- 
sure bearing upon the latter will be the sum of the force ap- 
plied by the operator's hand, and of the resistance offered by 



the tooth which is being extracted. Usually it will be foiand 
needful that the fulcrum should be in front of the tooth that 
is to be taken out, but this can hardly be laid down as a rule. 

Fig. 27. 

Fig. 28, 



Diagrams of Elevator — front and side views. The blade being tbe exact 
size, the handle should be four inches long. 

During the insertion of the blade into the alveolus, the end 
of the first finger of the operating hand must be pressed firm- 
ly upon it, within half an inch of its end, and also upon the 
side of the fulcrum, or of the tooth to be extracted. Thus 
any puncturing of the tongue or cheek may be quite pre- 
vented in the event of a slip, a by-no-means unusual event. 



Fia. 29. 

since the force needed to insert the instrument is fre- 
quently very great. After the insertion of the blade its 
handle should be carried forward towards the median line. 
At the same time the instrument should be slightly rotated 
on its long axis, so that the lower edge of its blade may 
tend to lift up and loosen the stump from its socket. Dur- 
ing these operations the eye should be fixed intently upon 
the fulcrum, which may, if care be not taken, readily start 
from its position. Thus used, the elevator serves to raise 
and slightly detach a tooth, but for the completion of its 
extraction, which is thus rendered an easy task, the for- 
ceps may be required. For the removal of lower wisdom 

teeth the elevator is very serviceable, 
and it should then be thrust freely 
into the alveolar process between the 
second and third molars. 

The Screw Extractor is of use for 
removal of decayed stumps of upper 
incisors or canines. The fangs gene- 
rally need to be opened up with a 
conical four- sided drill, passed up the 
fang canal, and rotated between the 
Snger and thumb ; after which the 
instrument may be carefully screwed 
into the fang, which should be re- 
moved by gentle traction and rock- 
Diagram of a scre\^' ex- °* 
tractor for removal of 
stumps of upper incisors 
and canines. 


Chapter IX, 


Nitrous Oxide, Chloroform, and Ether are employed to 
prevent pain during extractions. Inasmuch also as they 
lessen the shock of an operation they are beneficial when 
dealing with children and those whose health is enfeebled. 

Nitrous oxide is now supplied in a liquid form, condensed 
by pressure and cold into strong wrought iron bottles, 
whence it is liberated into the bag from which it is to be 
inhaled. It is an anaesthetic well suited for minor extrac- 
tions, and may safely be re -inspired when a second or 
third tooth has to be removed. It may be applied to 
patients of all ages, but is very suitable for young healthy 
persons fairly free from nervousness. It has great value 
when anaesthesia is needed by one whose heart is enfeebled 
from age or ill-health, and then should be greatly preferred 
to chloroform, since it acts as a stimulant to the weak 
organ, while the latter tends to depress its action. Ner- 
vous, hysterical girls, will frequently not take ** gas " well, 
and for such chloroform should be used, and will usually 
be found quite safe and efficient. A sine qua non in the 
employment of nitrous oxide is a free and full expansion 
of the chest during inspiration, and this the highly strung 
nervous patient is frequently quite unable to effect. It 


may be breathed until blueness of the face and commenc- 
ing stertor indicate that the right degree of insensibihty 
has been attained. This, if the mask fit so accurately 
that no air be introduced with the inhaled gas, is usually 
arrived at within 50 to 80 seconds from the commencement 
of inhalation. The extraction should of course be per- 
formed as rapidly as possible after withdrawing the mask, 
and great care needs then to be taken lest the tooth slip 
from the grasp of the forceps down the trachea of the 
patient, and lest a like accident occur with the gag or 
prop that has been used to keep the jaws apart. To pre- 
vent the latter a short piece of thin twine should always be 
attached to the gag, which should be of a telescopic or 
sliding pattern. 

Fig. 30. 

A telescopic gag or moutli prop for use during inhalation of nitrous oxide. 
It should be placed between the front teeth before the gas is inhaled. 

Chloroform is useful when many teeth have to be ex- 
tracted, or when from nervousness and absence of deep 



breathing the gas is contra-indicated. In a word, with 
a weak heart use gas rather than chloroform, and for 
a nervous hysterical female employ chloroform rather than 

Fig. 31. 

A mouth opener to be used with the administration of chloroform. 

gas. The administration of chloroform for dental pur 


poses should never be pushed to any extent, and before 
stertor and relaxation of the muscles show that the third 
stage of anaesthesia has been reached, the mouth should be 
forcibly opened by a powerful screw gag placed between 
the upper and lower bicuspid teeth. The gag should be 
held by an assistant between the bicuspids while the oper- 
ation is completed, and thus, while the sense of pain is 
dulled or entirely removed, we avoid causing that nausea 
and prostration which generally follow upon a large use 
of chloroform. 

Ether is used at times for patients of middle age, but for 
dental purposes is not very convenient. It causes great 
excitement, salivation, and bronchial irritation, also its 
pungent vapor is apt to inconvenience the operator. 

The undesirability of employing any anaesthetic, be it gas, 
ether, or chloroform, without the presence and assistance 
of a companion, who should be a qualified medical practi- 
tioner, needs hardly to be indicated. 

The preparation of the Mouth for the Insertion of Frames, — 
Artificial teeth are now made of mineral materials only, 
and are carried on a base of either gold or vulcanite. 

They are worn for the sake of appearance, and to prevent 
lisping during speech, as when an artificial incisor is 
adopted ; to restore or increase power of mastication, as 
when molars and bicuspids are inserted ; or to serve as 
props when all the back teeth of one or both jaws have 
been lost. Thus they prevent the lower jaw from approxi- 
mating too closely to the upper,^ and so directly tend to 
preserve the upper front teeth, which would otherwise be 
bitten out and loosened by the increased pressure upon 


their back surfaces of the lower incisors and canines. 
This last is certainly not one of their least useful duties. 
Further, by keeping the jaws apart, they prevent that pro- 
trusion of the inferior maxilla, and raising of the chin 
towards the nose, that characterises the aged. 

After deciding from any of the foregoing reasons that 
frames should be worn, it is usually desirable that any 
greatly decayed, or very loose teeth, or tender stumps 
should be removed ; and after such extractions an interval 
of from a day or two to six months should elapse before 
the models of the mouth are obtained to which frames are 
to be made. The wax impression should indeed not be 
taken until absorption of the alveolar process is well ad- 
vanced or completed. Only a short delay, however, need 
occur if before their removal the extracted teeth have been 
very loose, since already much of their sockets has disap- 
peared ; and if there be necessity for immediate wearing of 
artificial teeth, the impressions may be taken within a 
week or so of the operation. From these a temporary 
frame may at once be made, to be replaced by one of a 
more permanent character at the end of a year or so, when 
the alveolar ridge has settled down somewhat to its ulti- 
mate level. 

Tartar or Salivary Calculus. — This earthy deposit, which 
consists of lime salts with animal matter, is found to 
collect around the teeth under these circumstances. 

I. At the back of the lower incisors and canines, which is 
a part of the mouth always escaping that friction from the 
tooth brush and from the passage of food during mastica- 
tion, which tends to polish the surface of the teeth and to 
prevent lodgment thereon of calcareous particles. 


II. Upon and around any masticating tooth which from 
decay has become tender to pressure and change of tem- 
perature, and so has got thrown out of work. Thus, if 
from a tender molar the side of the mouth on which it is 
j)laced is unused, the buccal and lingual surfaces of molars 
and bicuspids of both upper and lower jaws on that side 
will shortly become much coated with deposit, and its occur- 
rence may be accounted for, as in the previous case, by 
the absence of the cleansing influence of friction. 

III. Towards middle life upon the necks of teeth 
w^hich from absorption of the alveolar process and gum are 
becoming exposed, and probably in such cases the growth 
of the deposit is but a sequence to the absorption and in 
no manner its cause. 

The removal of tartar may be readily effected by detach- 
ing it from below upwards with a strong excavator, and thus 
it may be scaled off the surface of the teeth, which should 
if loose be steadied with the fingers of the left hand. Its 
formation is undesirable since it is apt to induce an irri- 
tated state of the gums and to form a lodgment for par- 
ticles of food. 




A BSORPTION of temporary 
-^ ^ fangs, 2 
Absorptive papilla, 2 
Abortive teeth, 12 
Antiseptic treatment of fang 

canal, 38 
Anaesthetics for dental operations, 

Arsenic, application of, 35 
Artificial teeth, preparation of the 

mouth for, 78 

reasons for employment of, 78 

Attrition, 54 

/^ ARIES of crown of tooth, 28 
^^ Caries of neck of tooth, 29 
Caries, its first stage, 31 

— its second stage, 36 

— its third stage, 46 
Chloroform, 76 
Closure of jaws, 48 
Cryptogam, Leptothryx Buccalis, 


T~^ECAY of teeth, causes of, 28 
^^-^ Decay of first molars, 29 
Decay of temporary teeth, 4 
Dilacerated teeth, 12 
Dislocation of teeth, 56 

T^ LEVATOR, description and 
-■-^ use of, 72 

Enamel, defective, 28 
Eruption, retarded, 10 

— of temporary teeth, i 

— of permanent teeth, 6 
Ether, 78 

Excavators, their form and use, 24 
Extraction of teeth, reasons for, 57 

— of a wrong tooth, 63 

— of temporary teeth, 4 

— for the cure of irregularity, 15 

— symmetrical, 16 

TRILLING of teeth temporarily, 

Fistulous opening through cheek, 





Forceps, their mode of using, 59 

— their general characters, 65 
Fracture of a tooth by forceps, 61 

— of alveolar process during ex- 
traction, 63 

/^^ AS pressure on the nerve, 52 
^^ Geminated teeth, 12 
Gum, lancing of, 2 
Gum-boil, 44 

Gum, laceration of, during extrac- 
tion, 64 
Gutta-percha as a filling, 34 

TT HEMORRHAGE after ex- 
-■- -^ traction, 65 
Honeycombed teeth, 13 
Hunter's denuding process, 54 
Hutchinson's teeth, 13 

TRREGULARITY in positions 
■^ of teeth, causes of, 14 


AWS, closure of, 48 


EPTOTHRYX Buccalis, 29 

IV /TECHANICAL injuries of 
^^^ teeth, 54 

Mirror for mouth examination, 26 
Myeloid tumours of jaw, 10 

"\T ERVE devitalizing by arsenic 

Nerve, death of, 37 

— exposure of, 35 

— extraction of, 38 
Neuralgia, 53 
Nitrous oxide gas, 75 



"PERIODONTITIS, acute, 41 
•^ Periodontitis, cause of, 40 
Periodontitis, chronic, 43 
Permanent teeth, to distinguish, 
from temporary, 8 

T) EGULATING plates, 17 


Rhizodontropy, 45 

SALIVARY calculus, 79 
Screw extractor, use of, 74 
Stopping temporary teeth, 4 
Strumous teeth, 13 



Supernumerary teeth, 10 
Symmetrical extraction, 16 
Syphilitic teeth, 13 

npARTAR, 79 
■^ Teeth, eruption of tem- 
porary, I 

Teeth, decay of temporary, 4 

— ulceration through gum of fangs 
of, 5 

Tic doloureux, 53 

Tooth-ache, 50 

Torsion of teeth, 19 

Tooth powder, 55 

T T LCERATION through gums 
^^ of fangs of temporary 
teeth, 5 


-shaped jaw, 22 

TT TEARING down of crowns 

^ ^ of teeth, 54 

Wisdom teeth, eruption of, 7 
extraction of, 7 







The ? Quiz- Comp ends f 



Students' Manuals and Text-Books 



Medical Booksellers, Imporiers and Publishers, 


*** For sale by all Booksellers, or any book will be sent by mail, 
postpaid, upon receipt of price. Catalogues of books on all branches 
of Medicine, Dentistry, Pharmacy, etc., supplied upon application. 



For Use in the Quiz Class and when 

Preparing for Examinations. 

Price of Each, Bound in Cloth, $1.00 Interleaved, $1.25. 

Based on the most popular text-books, and on the lec- 
tures of prominent professors, they form a most complete 
set of manuals, containing information nowhere else 
collected in such a condensed, practical shape. The 
authors have had large experience as quiz-masters and 
attaches of colleges, with exceptional opportunities for 
noting the most recent advances and methods. The 
arrangement of the subjects, illustrations, types, etc., are 
all of the most improved form, and the size of the books 
is such that they may be easily carried in the pocket. 

No. 1. ANATOMY. (Illustrated.) 

A Compend of Human Anatomy. By Samuel O. L. 
Potter, m.a., m.d., U. S. Army. With 63 Illustrations. 

** The work is reliable and complete, and just what the student 
needs in reviewing the subject for his examinations.*' — The Physi- 
cian and Surgeon's Investigator , Buffalo, N. Y. 

** To those desiring to post themselves hurriedly for examination, 
this little book will be useful in refreshing the memory/' — New 
Orleans Medical and Surgical yournal. 

"The arrangement is well calculated to facilitate accurate memo- 
rizing, and the illustrations are clear and good." — North Carolina 
Medical Journal. 

Nos. 2 and 3. PRACTICE. 

A Compend of the Practice of Medicine, especially 
adapted to the use of Students. By Dan'l E. Hughes, 
M.D., Demonstrator of Clinical Medicine in Jefferson 
Medical College, Philadelphia. In two parts. 
Part I. — Continued, Eruptive, and Periodical Fevers, 
Diseases of the Stomach, Intestines, Peritoneum, Biliary 
Passages, Liver, Kidneys, etc., and General Diseases, etc. 
Part II. — Diseases of the Respiratory System, Circu- 
latory System, and Nervous System ; Diseases of the 
Blood, etc. 

*^* These little books can be regarded as a full set of 
notes upon the Practice of Medicine, containing the 
Price of each Book, Cloth, $1.00. Interleaved for Notes, $1.25. 


Synonyms, Definitions, Causes, Symptoms, Prognosis, 
Diagnosis, Treatment, etc., of each disease, and includ- 
ing a number of new prescriptions. They have been 
compiled from the lectures of prominent Professors, and 
reference has been made to the latest writings of Pro- 
fessors Flint, Da Costa, Reynolds, Bartholow, 
Roberts and others. 

** It is brief and concise, and at the same time possesses an accu- 
racy not generally found in compends." — yas. M. French, M.D.^ 
Ass't to the Prof, of Practice, Medical College of Ohio, Cincinnati. 

*' The book seems very concise, yet very comprehensive. . . . 
An unusually superior book." — Dr. E. T. Bruen, Demonstrator 
of Clinical Medicine , University of Pennsylvania. 

" I have used it considerably in connection with my branches in 
the Quiz-class of the University of La." — J. H. Bemiss, New 

" Dr. Hughes has prepared a very useful little book, and I shall 
take pleasure in advising my class to use it." — Dr. George W. 
Hall, Professor of Practice, St. Louis College of Physicians and 

No. 4. PHYSIOLOGY. Second Ed. 

A Compend of Human Physiology, adapted to the use 
of Students. By Albert P. Brubaker, m.d.. De- 
monstrator of Physiology in Jefferson Medical College, 
Philadelphia. Second Ed. Enlarged and Revised. 
*' Dr. Brubaker deserves the hearty thanks of medical students 
for his Compend of Physiology. He has arranged the fundamental 
and practical principles of the science in a peculiarly inviting and 
accessible manner. I have already introduced the work to my 
class." — Maurice N. Miller, M.D., Instructor in Practical His- 
tology, formerly Demonstrator of Physiology, University City of 
New York. 

** 'Quiz-Compend* No. 4 is fully up to the high standard estab- 
lished by its predecessors of the same series." — Medical Bulletin, 

** I can recommend it as a valuable aid to the student." — C. N. 
Ellinwood, M.D., Professor of Physiology, Cooper Medical Col- 
lege, San Francisco. 
'* This is a well written little book." — London Lancet. 

A Compend of Obstetrics. For Physicians and Students. 

By Henry G. Landis, m.d., Professor of Obstetrics 

and Diseases of Women, in Starling Medical College, 

Columbus. 22 Illustrations. 

" We have no doubt that many students will find in it a most 
valuable aid in preparing for examination." — The American Jour- 
nal of Obstetrics. 

" It is complete, accurate and scientific. The very best book ot 
its kind I have seen." — y. S. Knox, M.D.^ Lecturer on Obstetrics , 
Rush Medical College, Chicago. 

Price of each Book, Cloth, $1.00. Interleaved for Notes, $1.25. 


** I have been teaching in this department for many years, and am 
free to say that this will be the best assistant I ever had. It is ac- 
curate and comprehensive, but brief and pointed." — Prof. P. D. 
Yosty St. Louis. 

No. 6. MATERIA MBDIOA. Revised Ed. 

A Compend on Materia Medica and Therapeutics, with 
especial reference to the Physiological Actions of 
Drugs. For the use of Medical, Dental, and Pharma- 
ceutical Students and Practitioners. Based on the New 
Revision (Sixth) of the U. S. Pharmacopoeia, and in- 
cluding many unofficinal remedies. By Samuel O. 
L. Potter, M.A.,M.D., U. S. Army. 

" I have examined the little volume carefully, and find it just 
such a book as I require in my private Quiz, and shall certainly re- 
commend it to my classes. Your Compends are all popular here in 
Washington." — jfohn E. Brackett, M.D., Professor of Materia 
Medica and Therapeutics, Howard Medical College y Washington. 

" Part of a series of small but valuable text-books. . . . While 
the work is, owing to its therapeutic contents, more useful to the 
medical student, the pharmaceutical student may derive much use- 
ful information from it." — N. V. Pharmaceutical Record. 

No. 7. CHEMISTRY. Revised Ed. 

A Compend of Chemistry. By G. Mason Ward, m.d.. 
Demonstrator of Chemistry in Jefferson Medical Col- 
lege, Philadelphia. Including Table of Elements and 
various Analytical Tables. 
*' Brief, but excellent, ... It will doubtless prove an admirable 

aid to the student, by fixing these facts in his memory. It is worthy 

the study of both medical and pharmaceutical students in this 

branch." — Pharmaceutical Record^ New York. 


A Compend of Visceral Anatomy. By Samuel O. L. 
Potter, m.a., m.d., U. S. Army. With 40 Illustrations. 

***This is the only Compend that contains full descriptions of the 
viscera, and will, together with No. i of this series, form the only 
complete Com.pend of Anatomy published. 

No. 9. SURGERY. Second Edition. 

A Compend of Surgery; including Fractures, Wounds, 
Dislocations, Sprains, Amputations and other opera- 
tions. Inflammation, Suppuration, Ulcers, Syphilis, 
Tumors, Shock, etc. Diseases of the Spine, Ear, Eye, 
Bladder, Testicles, Anus, and other Surgical Diseases. 
By Orville Horwitz, a.m., m.d., with 62 Illustra- 
tions. Second Edition. Enlarged and Revised. 

Price of Each Book, Cloth, $1.00. Interleaved for Notes, $1.25. 




A Compend of Organic Chemistry, including Medical 
Chemistry, Urine Analysis, and the Analysis of Water 
and Food, etc. By Henry Leffmann, m.d., Pro- 
fessor of Clinical Chemistry and Hygiene in the Phila- 
delphia Polyclinic ; Professor of Chemistry, Penn- 
sylvania College of Dental Surgery ; Member of the 
N. Y. Medico-Legal Society. Cloth. $i.oo. 

Interleaved, for the addition of Notes, ^1.25. 

Nature of Organic Bodies, Transformations under various con- 
ditions. Organic Synthesis. Homologous and Isomeric Bodies. 
Empirical and Rational formulae. Classification of Organic Bodies. 
Hydrocarbon. Derivatives of Hydrocarbons, Alcohols and Ethers. 
Benzenes and Turpenes. Fat Acids, Oils and Fats, Sugars, Gluco- 
sides. Cyanogen Compounds. Amines and Amides. Alkaloids. 
Ptomaines. Animal Chemistry. Nutrition and Assimilation. 
Food, Water and Air. Urinary Analysis. Index. 

The Essentials of Pathology. 


Professor of Physiology in Starling Medical College, Columbus, O . 

With 47 Illustrations. 12mo. Cloth. Price $2.00. 

***The object of this book is to unfold to the beginner the funda- 
mentals of pathology in a plain, practical way, and by bringing them 
within easy comprehension to increase his interest in the study ot 
the subject. Though it will not altogether supplant larger works, 
it will be found to impart clear-cut conceptions of the generally 
accepted doctrines of the day, and to prevent confusion in the mind 
of the student. 




Diseases of the Heart and Lungs. 



Demonstrator of Clinical Medicine in the University of Pennsyl- 
vania, Assistant Physician to the University Hospital, etc. 

Second Edition, Revised. With new Illustrations. 12mo. $1.50. 

*:^*The subject is treated in a plain, practical manner, avoiding 
questions of historical or theoretical interest, and without laying 
special claim to originality of matter, the author has made a book 
that presents the somewhat difficult points of Physical Diagnosis 
clearly and distinctly. 


TYSON, ON THE URINE. A Practical Guide to 
the Examination of Urine. For Physicians and Stu- 
dents. By James Tyson, m.d.. Professor of Path- 
ology and Morbid Anatomy, University of Pennsylva- 
nia. With Colored Plates and Wood Engravings. 
Fourth Edition. i2mo, cloth, ^1.50 

Minor Surgery and Bandaging. By Christopher 
Heath, m.d.. Surgeon to University College Hospital, 
London. 6th Edition. 115 111. i2mo, cloth, I2.00 

Students and Physicians. 4 Colored Plates and 65 
Wood Engravings. Demi 8vo. Cloth, ^4.00. 

Examinations. A Description and Explanation of the 
Methods of Performing them. By Prof. Rudolph 
ViRCHOW, of Berlin. Translated by Dr. T. B. Smith. 
2d Ed. 4 Lithographic Plates. i2mo, cloth, ^1.25 

CIES. What To Do First in Accidents and Emer- 
gencies. A Manual Explaining the Treatment of 
Surgical and other Accidents, Poisoning, etc. By 
Charles W. Dulles, m.d.. Surgeon Out-door De- 
partment, Presbyterian Hospital, Philadelphia. Col- 
ored Plate and other Illustrations. 32mo, cloth, .75 

ture and Treatment. By Lionel S. Beale, m.d., 
F.R.s. Second Edition. Revised, Enlarged and Illus- 
trated. 283 pages. 8vo. 

Paper covers, 75 cents; cloth, ^1.25 

Hemorrhoids, Painful Ulcer, Stricture, Prolapsus, and 
other Diseases of the Rectum ; Their Diagnosis and 
Treatment. By Wm. Allingham, m.d. Fourth Re- 
vised and Enlarged Edition. Illustrated. 8vo. 

Paper covers, 75 cents; cloth, ^1.25 

OF MEDICINE. A New (Seventh) Edition. 2 
Vols. 8vo. Cloth, ^12.00; Leather, ^14.00. 



The Chemical Analysis of the Urine. By John Mar- 
shall, M.D., Chemical Laboratory, University of Penn- 
sylvania, and Prof. E. F. Smith. Illus. Cloth, ^i oo 

Dressings, Bandaging, Ligation, Amputation, etc. By 
J. EwiNG Mears, M.D., Demonstrator of Surgery in 
Jefferson Med. College. 227 Illus. 2d Ed. In Press. 

KIRKE'S PHYSIOLOGY. A Handbook for Stu- 
dents. Eleventh Edition, 1884. 466 Illustrations. 
Demi 8vo. Cloth, ^5.00 

tory and Present State. By Prof. James Tyson, m.d. 
Second Edition. Illustrated. i2mo, cloth, ;^2.oo 

MEADOWS' MIDWIFERY. A Manual for Stu- 
dents. By Alfred Meadows, m.d. From Fourth 
London Edition. 145 Illustrations. 8vo, cloth, $2.00 


Containing the Doses and Uses of all the principal 
Articles of the Materia Medica, etc. Eleventh Edi- 
tion. 32mo, cloth, ^i.oo; pocket-book style, ^1.25 

taining Lists of Terms, Phrases, Contractions and 
Abbreviations used in Prescriptions, Explanatory Notes, 
Grammatical Construction of Prescriptions, etc., etc. 
By Prof. Jonathan Pereira, m.d. Sixteenth Edi- 
tion. 32mo, cloth, ^i.oo; pocket-book style, ^1.25 


CON. A Medical Lexicon, containing correct Pro- 
nunciation and Definition of Terms used in Medi- 
cine and the Collateral Sciences. Thirtieth Edition. 
Very small pocket size. Red Edges. 

Cloth, 75 cents; pocket-book style, ^i.oo 


Student's Medical Lexicon, giving Definition and Pro- 
nunciation of all Terms used in Medicine, v^^ith an 
Appendix giving Poisons and Tlfeir Antidotes, Abbre- 
viations used in Prescriptions, Metric Scale of Doses, 
etc. 24mo, cloth, ^i.oo; pocket-book style, S1.25 



A Text-book of Medical Jurisprudence and Toxicology. By 
John J. Reese, m. d., Professor of Medical Jurisprudence and 
Toxicology in the Medical and Law Departments of the University 
of Pennsylvania ; Vice-President of the Medical Jurisprudence So- 
ciety of Philadelphia ; Physician to St. Joseph's Hospital ; Corres- 
ponding Member of the New York Medico-legal Society. One 
Volume. Demi Octavo. 606 pages. Cloth, ^4.00 ; Leather, $5.00. 

" Professor Reese is so well known as a skilled medical jurist 
that his authorship of any work virtually guarantees the thorough- 
ness and practical character of the latter. And such is the case in 
the book before us. * * * * We might call these the 
essentials for the study of medical jurisprudence. The subject 
is skeletonized, condensed, and made thoroughly up to the wants ot 
the general medical practitioner, and the requirements of prose- 
cuting and defending attorneys. If any section deserves more dis- 
tinction than any other, as to intrinsic excellence, it is that on toxi- 
cology. _ This part of the book comprises the best outline of the 
subject in a given space that can be found anywhere. As a whole, 
the work is everything it promises and more, and considering its 
size, condensation, and practical character, it is by far the most 
useful one for ready reference that we have met with. It is well 
printed and neatly bound. — ^V. V. Medical Record, Sept. 13th, 1884 . 




University of Breslau, 

Authorized Translation from the Third German Edition, 

By EDGAR F. SMITH, M.A., Ph.D., 

Professor of Chemistry in Wittenberg College, Springfield^ Ohio; 
formerly in the Laboratories of the University of Pennsyl- 
vania: Member of the Chemical Society of Berlin. 

12mo. 89 Wood-cuts and Col. Lithographic Plate of Spectra. $2.00 

In the chemical text-books of the present day, one of the striking 
features and difficulties we have to contend with is the separate 
presentation of the theories and facts of the science. These are 
usually taught apart, as if entirely independent of each other, and 
those experienced in teaching the subject know only too well the 
trouble encountered in attempting to get the student properly in- 
terested in the science and in bringing him to a clear comprehension 
of the same. In this work of Prof, von Richter, which has been 
received abroad with such hearty welcome, two editions having 
been rapidly disposed of, theory and fact are brought close together, 
and their intimate relation clearly shown. From careful observa- 
tion of experiments and their results, the student is led to a correct 
understanding of the interesting principles of chemistry. 

In preparation, "ORGANIC CHEMISTRY," By the same 
author and translator. 





By Gerald F. Yeo, m.d., f.r.c.s., Professor of Physi- 
ology in King's College, London. Small Octavo. 750 
pages. Over 3CK) carefully printed Illustrations. 

PRICE, CLOTH, $4.00; LEATHER, $5.00. 

** By his excellent manual, Prof. Yeo has supplied a want which 
must have been felt by every teacher of physiology. * * * * 
In conclusion, we heartily congratulate Prof. Yeo on his work, 
which we can recommend to all those who wish to find within a 
moderate compass a reliable and pleasantly written exposition of 
all the essential facts of physiology as the science now stands." — 
The Dublin yournal of Med. Science. 

"The work will take a high rank among the smaller text-books 
of Physiology." — Prof. H. P. Bowditch, Harvard Med. School, 

" The brief examination I have given it was so favorable that I 
placed it in the list of text-books recommended in the circular of 
the University Medical College." — Prof. Lewis A. Stimpson, 
M. D.y37 East 33d Street, New York. 

" For students' use it is one of the very best text-books in Physi- 
ology." — Prof L. B. How, Dartmouth Med. College, Hanover, 




Of the University of Pennsylvania. 
263 PAGES. CLOTH. PRICE ^2.00. 
*^* It is the object of Prof. Rindfleisch to present in 
this volume of moderate size the fundamental principles 
of Pathology A large number of the general processes 
which underlie disease, a knov^ledge of w^hich is essen- 
tial to the practical physician, are plainly presented. 
They include, among others, inflammation, tumor forma- 
tion, fever, derangements of nutrition, including atrophy, 
derangements of the movement of the blood, of blood 
formation and blood purification, hyperaesthesia, anaesthe- 
sia, convulsions, paralysis, etc. The well-know^n reputa- 
tion of the author, his thorough familiarity with and his 
method of treating the subject, make this most recent work 
peculiarly useful to the student, as well as to the prac- 
ticing physician who wishes to brush up his pathology. 

yust Published. 


A Handbook of the Diseases of the Skin, their Di- 
agnosis and Treatment. By Arthur Van Harlingen, M.D., 
Professor of Diseases of the Skin in the Philadelphia 
Polyclinic, Consulting Physician to the Dispensary for 
Skin Diseases, etc. Illustrated by two colored litho- 
graphic plates. 

12mo. 284 PAGES. CLOTH. PRICE $1.75. 
*:}:*This is a complete epitome of skin diseases, arranged in al- 
phabetical order, giving the diagnosis and treatment in a concise, 
practical way. Many prescriptions are given that have never been 
published in any text-book, and an article incorporated on Diet. 
The plates do not represent one or two cases, but are composed of a 
number of figures, accurately colored, showing the appearance of 
various lesions, and will be found to give great aid in diagnosing. 


The Practice of Medicine and Surgery, as applied to the 
Diseases of Women. By W. H. Byford, a.m., m.d., 
Professor of Gynaecology in Rush Medical College; 
of Obstetrics in the Woman's Medical College ; Sur- 
geon to the Woman's Hospital; President of the 
American Gynaecological Society, etc. Third Edition. 
Revised and Enlarged; much of it Rewritten; with 
over 1 60 Illustrations. Octavo. 

PRICE, CLOTH, $5.00; LEATHER, $6.00. 
" The treatise is as complete a one as the present state of our 
science will admit of being written. We commend it to the diligent 
study of every practitioner and student, as a work calculated to in- 
culcate sound principles and lead to enlightened practice " — New 
York Medical Record. 

" The author is an experienced writer, an able teacher in his de- 
partment, and has embodied in the present work the results of a 
wide field of practical observation. We have not had time to read 
its pages critically, but freely com.mend it to all our readers, as one 
of the most valuable practical works issued from the American 
press/' — Chicago Medical Examiner. 


By MoRELL Mackenzie, m.d., Senior Physician to the 

Hospital for Diseases of the Chest and Throat; Lecturer 

on Diseases of the Throat at the London Hospital, etc. 

Vol. I. Including the Pharynx, Larynx, Trachea, 

etc. 112 Illustrations. Cloth, ^4.00 ; Leather, ^5.00 

Vol. II. Diseases of the CEsophagus, Nose and 

, Naso-pharynx, with Formula and 93 Illustrations. 

Cloth, ^3.00; Leather, ^4.00 

The two volumes at one time. Cloth, $6.00 ; Leather, $7.50 



I -^^^ ,/V^^/^V<r 






__' 1. 


' + 


. 1 


• ^ 

*.•' "* , • -